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An intrathecal pain pump implant can help with long-term (chronic) pain or cancer pain. It delivers pain medication via a tiny, flexible tube.
The tube is placed in the area surrounding the spinal cord. The intrathecal space is the gap between the spinal cord and the tissue (membrane) that covers the cord. Cerebrospinal fluid (CSF) is a liquid found in this area.
The device offers a lot of benefits, so a common question is, “Does Medicare cover pain pumps?”
In this article, we answer the question in clear, plain English. You will also find the average costs of pain pumps and other helpful info.
Does Medicare Cover Pain Pumps?
The short answer is yes; Medicare will cover the cost of pain pumps. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your pain pumps. Below we look at what these are so you know what to expect.
Original Medicare Coverage of Pain Pumps
Original Medicare (Medicare Part A and Part B) provides coverage for pain pumps. Original Medicare provides coverage for your pain pumps if considered medically necessary.
First, your healthcare provider must order the operation. Then, Original Medicare can provide coverage.
Which Part of Original Medicare Covers Pain Pumps?
Medicare Part B covers pain pumps. Medicare Part B considers pain pumps as Durable Medical Equipment or DME.
Part B pays for the rental or purchase of a pain pump.
However, as previously stated, your condition must be medically necessary. To qualify as medically necessary, it has to follow these certain conditions:
- The administration of the medication requires the intrathecal or epidural route. It is for a long-term basis
- Both oral and subcutaneous treatment are ineffective or complicated by unacceptable side effects
- You have a medical condition that requires the use of an infusion pump for pain relief. Other methods of treatment modalities have failed
- The type and dosage of the medication must alleviate or reduce the effects of the pain
So, if you qualify, what’s next? A preliminary trial of intraspinal opioid or non-opioid drugs will take place. It must use a temporary intrathecal/epidural catheter. This will substantiate acceptable pain relief.
The degree of side effects includes effects on the activities of daily living and patient acceptance and compliance.
The medications used for the pain pump must be appropriate for treating the patient. Certain drugs may be covered by either Medicare Part B or Part D.
What does Part B Cover?
For Medicare Part B to provide coverage for your pain pump, your DME supplier must request prior authorization. Once approved, Medicare Part B covers 80 percent of the costs of a pain pump. You will pay for the remaining 20 percent.
Medicare Advantage Coverage of Pain Pumps
Medicare Advantage plans (Medicare Part C) also provide coverage for pain pumps. These plans will cover the same devices, procedures and treatments Original Medicare covers but offer additional benefits.
What a plan covers and how much you’ll pay out of pocket for these benefits will vary from plan to plan.
How Much Do Pain Pumps Cost?
The national average cost of insertion of intrathecal/epidural catheter and drug infusion pump ranges from $29,000 and $60,500.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series, including: Does Medicare cover jaw surgery?