Will Medicare pay for cervical artificial disc replacement?

Does Medicare cover cervical artificial disc replacement?

If you’re over 60, Medicare will not pay for cervical disc replacement. For patients 60 years of age and younger, a local coverage determination must be made, as Medicare does not offer a national coverage plan.

Whatever your age, you may be able to pursue other options, so seek advice from your local health insurance broker.

To find the best local insurance coverage or a Medicare Supplement plan, enter your ZIP code above, and get started now.

How much does cervical spine surgery cost?

The advantage of cervical artificial disc replacement surgery is, first and foremost, the cost. Traditional spinal fusion surgery can cost well over $100,000. In contrast, artificial disc replacement, or cervical arthroplasty, is a fraction of the expense. 

The reduction in cost comes at its own price, however. The procedure is considered investigational at this point, and thus not covered by national Medicare plans. However, your local Medicare plan may have the answer you need.

Does Medicare cover cervical disc replacement?

According to the Centers for Medicare and Medicaid Services, local coverage determinations (LCD) may be made in each case, so seek advice from your Medicare representative. Several LCDs include cervical artificial disc replacement surgery in their coverages.

Palmetto GBA, for instance, considers prosthetic cervical discs that are approved by the Food and Drug Administration to be reasonable and necessary for the treatment of some Medicare beneficiaries. They do have restrictions, of course, so check your plan to find out if you qualify. 

Many private insurance companies share the same approach to qualification as your Medicare LCD, so it is helpful to be familiar with the requirements that need to be met. 

Is disc replacement surgery covered by insurance?

Often it is.

There are several private insurance companies that will cover cervical artificial disc replacement, or CDR. Each of them has their own restrictions, but there are some general guidelines you should know about.

In order to qualify, you will have to navigate a series of steps to receive coverage. Once you and your doctor have determined that cervical disc replacement is right for you, you can decide if local Medicare coverage, or a private insurance policy is the best way to pay for your procedure.

Whatever your decision, it is likely you will need to meet the following conditions to qualify.

How to get Disc Replacement Surgery Covered by Insurance

As there are multiple conditions that can cause severe back pain, your symptoms must be caused by severe degenerative disc disease, diagnosed by a medical doctor. You will also likely need imaging of the affected area with X-ray, CT scan, or MRI scanning.

It generally must be shown that your condition is resistant to more conservative therapy treatments. Many insurance companies will require a period of treatment with anti-inflammatory medication, physical therapy, and methods such as chiropractic care and massage. 

Your quality of everyday life must be significantly impacted by your cervical disc pain. Discuss this situation with your doctor before pursuing disc surgery.

Smoking increases the risk of complications from disc replacement surgery, so you will likely be advised to quit smoking.

Age is a factor as well, as most surgeons will require skeletal maturity. In general, this occurs after the age of 25 when the bones have stopped growing. 

You will not be able to obtain coverage for your cervical disc replacement unless the artificial disc is approved by the Food and Drug Administration.

FDA approval satisfies the need for the procedure to be “reasonable and necessary”, as per guidelines set out by the Centers for Medicare and Medicaid. Insurance companies want this level of security as well.

There are also several conditions that would prevent the safe implantation of an artificial cervical disc, such as low bone-density, or a prior spinal fusion surgery. Check with your doctor to see if any of these conditions apply to you.

Cervical Disc Replacement and Medicare

Cervical artificial disc replacement is a complicated procedure. Finding the best way to pay for it is no picnic either. You may be able to find coverage through Medicare, or you may need to obtain a private insurance policy.

First determine if your condition meets the necessary criteria for the procedure. The checklist above should help, but if you are unsure, always ask your doctor.

Then seek out your local coverage determination to see if Medicare will cover you. If not, shop around to find the best private insurance coverage plan that meets your needs.

Finally, be certain you are getting the best quality device by using only FDA-approved artificial discs.

A great way to start your search is by letting us help you find the doctor, insurance company or advice you need. Enter you ZIP code below to find out more.

Case Studies: Medicare Coverage for Cervical Artificial Disc Replacement

Case Study 1: Successful Medicare Coverage

Patient: Mrs. Johnson, a 67-year-old Medicare beneficiary

Mrs. Johnson’s chronic neck pain caused by degenerative disc disease led to a recommendation for cervical artificial disc replacement (CADR) after conservative treatments proved ineffective. Medicare approved coverage for the procedure, and following the surgery, Mrs. Johnson experienced notable pain relief and improved functionality.

Case Study 2: Denied Medicare Coverage

Patient: Mr. Anderson, a 73-year-old Medicare beneficiary

Despite Mr. Anderson’s history of cervical spine degeneration and failed non-surgical treatments, Medicare denied coverage for his recommended cervical artificial disc replacement (CADR) surgery due to insufficient evidence of medical necessity. Consequently, he was left with the need to seek alternative funding sources or explore other treatment alternatives for his debilitating neck pain.

Case Study 3: Partial Medicare Coverage

Patient: Ms. Ramirez, a 70-year-old Medicare beneficiary

Ms. Ramirez, suffering from chronic neck pain and limited mobility caused by cervical disc degeneration, was recommended cervical artificial disc replacement by her physician. While Medicare approved partial coverage for the CADR surgery, the remaining expenses, including deductibles and co-payments, imposed a substantial financial burden on Ms. Ramirez.

Case Study 4: Prior Authorization and Medicare Coverage

Patient: Mr. Lee, a 69-year-old Medicare beneficiary

Upon recommendation from his physician, Mr. Lee received prior authorization from Medicare for cervical artificial disc replacement to address his cervical degenerative disc disease. With Medicare approving coverage for the CADR surgery, Mr. Lee underwent the procedure without facing substantial out-of-pocket expenses.