Insurance Coverage

Insurance Coverage for Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

The good news is Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation is covered by most health insurance plans, including Medicare and most worker’s compensation programs. Insurance providers generally require pre-authorization for SCS or DRG. Your clinic or hospital will need to get this pre-authorization for you first.

Below is some general information about health insurance, Medicare, Medicaid, and worker’s compensation coverage of SCS and DRG trial and permanent implantation. However, your physician’s office and your health insurance provider are the best resources for coverage questions and can provide you specific detail regarding your coverage benefits and out-of-pocket cost for Spinal Cord Stimulator (SCS) or Dorsal Root Ganglion (DRG) Stimulator trial and permanent implant.

Pre-Authorization

After determining that you are a candidate for Spinal Cord Stimulation (SCS) or Dorsal Root Ganglion (DRG) Stimulation, your physician and his/her office staff will provide your insurance company the documentation needed to complete the pre-authorization. The pre-authorization process generally takes about 15 to 30 days to complete once the insurance provider has determined that the criteria for medical necessity have been met.

Trial vs. Permanently Implanted System Coverage

Separate pre-authorizations are generally required for the temporary trial system and the long-term implanted system. For people who now manage their chronic pain with SCS therapy, the first step was what is called a trial, which is a test drive of a Precision™ SCS System.

Patients must experience a successful test drive in order to be covered for the long-term implanted system. Most insurance providers define a successful test drive as a patient experiencing pain relief of at least 50% during the 3- to 7-day* test drive, as determined by you and your physician. Your insurance company may require you to meet additional criteria in order to provide coverage.

A Summary of Pre-authorization Requirements for Different Types of Healthcare Coverage

Medicare does not pre-authorize or guarantee benefits. However, patients must meet the Medicare criteria for SCS coverage.
Medicaid requires pre-authorization for SCS procedures in many states. The pre-authorization process varies from state-to-state, so have your physician’s office check with your local Medicaid office to determine the pre-authorization process for your state.
Commercial Payers typically recommend pre-authorization for SCS procedures. Have your physician’s office check with each payer to verify benefits, coverage policies, plan limitations, and/or exclusions.
Worker’s Compensation typically requires pre-authorization for SCS treatment.

Managed Care (HMOs & PPOs)

Health Maintenance Organizations (HMOs) — HMO members often must receive their medical treatment from physicians and facilities within the HMO network. HMOs may require a referral authorization from the primary care physician to the specialist. In addition to a referral authorization, the plan may require a separate authorization for the services to be rendered.
Preferred Provider Organizations (PPOs) — These plans may not have pre-authorization requirements for outpatient surgery. Members may also receive treatment from physicians and facilities outside the network, but different benefits apply. The plan may allow benefits to be predetermined prior to a procedure or service. The center should schedule surgeries to allow for appropriate approval processing times. Predeterminations can take 15 to 30 days.

Health economics, pre-authorization, and reimbursement information provided by SpinalCordStim.com is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for educational purposes only and does not constitute reimbursement or legal advice. It is always the healthcare provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services that are rendered. Information included herein is current as of January 2015, but is subject to change without notice.

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