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Does Medicare Cover Vertiflex?

Does Medicare Cover Vertiflex?

In some cases, lower back pain may not be treatable with pain relief medications, massage or rest.

Lower back pain may signify lumbar spinal stenosis. In this condition, your spine narrows, causing pressure on your spine and nerves in your muscles. Surgery is an option, but a less invasive treatment called Vertiflex, a type of lumbar laminectomy, is available.

If this is a treatment that could help you or a loved one, a question you likely have is, “does Medicare cover Vertiflex?” In this article, we answer that question in clear, plain English. You will also find the average costs of lumbar laminectomies and other helpful info.

Does Medicare Cover Vertiflex?

The short answer is yes; Medicare will cover the cost of Vertiflex. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your Vertiflex. Below we look at what these are so you know what to expect.

Original Medicare

Original Medicare (Medicare Part A and Part B) provides coverage for Vertiflex. Original Medicare provides coverage for your Vertiflex if it is considered medically necessary. Your healthcare provider must first order the treatment for Original Medicare to provide coverage.

In 2014, the Centers for Medicare and Medicaid Services approved reimbursement for the medical service known as Percutaneous Image-Guided Lumbar Decompression, or PILD, and Totalis by Vertiflex. 

However, Original Medicare does not easily provide reimbursement coverage for PILD and Totalis. Original Medicare provides PILD and Totalis available to patients enrolled in and approved under “Coverage with Evidence Development.” 

Original Medicare also provides coverage for other back surgeries such as discectomy, laminectomy, and spinal fusion. 

Coverage for back surgery is provided by Medicare Part A if it takes place in an inpatient setting. Part A will cover 100 percent of the costs of hospital stays for up to 60 days. For days 61 to 90, Part A will still provide coverage, however, you will have a daily copayment. 

On the other hand, coverage for back surgery is provided by Medicare Part B if it takes place in an outpatient setting. Once approved, Medicare Part B covers 80 percent of back surgery costs. You will pay for the remaining 20 percent. 

Part C Coverage for Vertiflex

Medicare Advantage plans (Medicare Part C) also provide coverage for Vertiflex. These plans have to cover all the same benefits that Original Medicare does.

Part C plans will also cover various treatments and services that Original Medicare doesn’t. Each plan differs though in what additional benefits it offers and what the costs are.  

How Much Does Lumbar Laminectomy Cost?

A lumbar laminectomy is a procedure used to treat spinal stenosis. It usually costs somewhere from $50,000 to $90,000. Costs for the Vertiflex treatment are not readily available.

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 a Diagnostic Colonoscopy?

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Medicare Plan Tips Team

Annie Kaye is a writer and researcher who was thrown into the Medicare world while taking care of her ailing mother. Even with a degree in Library Science and a long history of fighting for what's right, she felt lost. She learned a lot about Medicare during that time and now writes to help others understand how the system works.