When it comes to insurance, most policies (including Medicare) cover back surgery, as long as it is deemed medically necessary by a doctor. But, insurance coverage can be confusing, which is why it’s important for patients to stay informed about their insurance coverage and what it entails.
Each insurance policy differs regarding what is covered and what is not. Additionally, there are a few things that can affect your level of coverage, so it’s important to be familiar with these aspects, to ensure you will have minimal out-of-pocket expenses. Things to keep in mind when reviewing insurance coverage before back surgery:
Reason for surgery.
Some insurance policies will only cover surgery relating to a specific diagnosis, so be sure to read into your policy before scheduling your surgery. If your insurance policy covers back surgery, the surgery will need to be deemed medically necessary for your insurance to cover it.
If your back surgery is due to a work-related injury, most insurance companies will require your company’s workers’ compensation coverage to pay for the procedure, rather than your personal insurance.
In-network vs. Out-of-network.
Some insurance policies don not offer out-of-network benefits to members and require diagnosis by a specialist within their network in order for them to cover the procedure. Policies that have both in-network and out-of-network benefits allow their members more flexibility when deciding on where to seek medical treatment for back pain. Be sure to check with your insurance company whether or not this applies to you.
Type of surgery recommended.
There are certain types of surgeries that your insurance may not cover. Check with the doctor to find out which type of surgery he or she recommends, and then follow-up with your insurance provider to ensure that they cover it. If back surgery is covered by your insurance carrier, your coverage will not change if you choose to have minimally invasive back surgery or traditional open-back surgery.
Benefit level covered.
Depending on your benefit level, some aspects of surgery or postoperative care may not be covered, such as medications and therapeutic medical equipment.
The key to understanding which procedures your insurance will or will not cover is communication. Speak with your insurance company, read the coverage information they send, and follow up with any questions you may have.