Although the U.S. Food and Drug Administration has approved several artificial disc replacement (ADR) devices for the lower (lumbar) spine, not all health insurance plans cover this procedure.
This procedure was developed as an alternative to lumbar fusion
for treating severe back pain caused by degenerative disc disease in the lower spine. It is also known as lumbar artificial disc surgery or total disc arthroplasty.
Unlike lumbar fusion surgery, replacing a damaged lumbar disc with an artificial one maintains the motion in the spine at that level. However, some health insurance companies still consider lumbar disc replacement to be an investigational procedure
Here is an overview of which major health insurance carriers do and don’t cover this procedure to date, and the requirements for qualifying for coverage. Insurers sometimes change their coverage policies, so check with your health insurer before scheduling a lumbar artificial disc replacement surgery.
Coverage of lumbar disc replacement surgery
Each health insurance company sets its own medical policies for which surgeries and medical procedures the health plans will cover.
These decisions are based on the benefits and risks, as well as the costs, of the surgeries and medical procedures. Insurers may change their list of covered procedures based on new information from clinical studies or changes in the cost of the procedures, for example.
The following health insurance companies currently cover artificial disc replacement surgery for the lumbar spine. However, all of these insurers have restrictions on which patients are eligible for this surgery. The companies include:
* Some of the Blue Cross Blue Shield plans
* Molina Healthcare Inc.
Some insurers still consider lumbar disc replacement surgery for degenerative disc disease to be an experimental and investigational procedure, so they do not cover it. These include:
* Some of the Blue Cross Blue Shield plans
Health insurance requirements for lumbar ADR
Even if a health insurance company covers lumbar disc replacement surgery, the company may place restrictions on which patients are eligible to have this procedure covered. These requirements vary from plan to plan, but in general they include the following.
Disc-related pain. Back pain can have many causes. In order for lumbar disc replacement surgery to be covered, the pain needs to be caused by degeneration of the discs in the lower spine.
Symptoms for at least six months. Some cases of low back pain go away over time. Health insurance companies generally require that the symptoms be present for at least six months — or 12 months for some plans — before an insurer will cover lumbar disc replacement surgery.
Pain not relieved by a program of conservative treatment. All surgeries carry some risk, so spine surgeons generally recommend conservative treatments first for non-urgent cases of low-back pain. Health insurers often require that patients try this program for at least six months to see if it relieves their pain and other symptoms. Conservative treatments are aimed at reducing inflammation, relieving pain, and improving function. They may include:
* Activity and lifestyle modifications
* Anti-inflammatory medications and pain relievers
* Chiropractic care
* Corticosteroid injections in the spine
* Home treatment program of flexibility and muscle-strengthening exercises
* Physical therapy
Imaging showing the presence of advanced disease in a single level of the lumbar spine. Before recommending lumbar disc replacement surgery, a spine surgeon will order an X-ray, MRI, or CT scan to determine the cause of the low back pain, and also to see which disc is damaged. A health insurance company will generally only cover a lumbar ADR surgery if there is moderate to severe damage in one lumbar disc
Pain severe enough to interfere with everyday activities. Pain caused by lumbar disc degeneration can range from mild to severe. Insurers will generally only cover a lumbar disc replacement surgery if the pain is moderate to severe, or if it severely impacts a person’s ability to do everyday activities such as household chores, standing for long periods, or doing essential job functions.
Age. Health insurance companies may place restrictions on which age groups can have a lumbar ADR surgery covered, such as people between 18 and 60 years old. This is due to the age range of patients included in the clinical studies to determine whether this procedure is safe and effective in older adults.
Use of an FDA-approved artificial disc replacement device. Insurers will only cover this procedure if the device being implanted is approved by the FDA, and approved for use in the part of the spine where it is being implanted.
Does Medicare cover lumbar disc replacement surgery?
Medicare does not cover lumbar artificial disc replacement surgery for enrollees who are 60 years or older
. The Centers for Medicare and Medicaid Services (CMS) writes on its website that this procedure “is not reasonable and necessary” for Medicare enrollees in this age group.
The decision by CMS is based on a lack of scientific evidence showing that the benefits of lumbar disc replacement outweigh the risks in people 60 years or older. The primary reason for this lack of evidence is that the clinical trials looking at this procedure have not specifically included this age group.
For Medicare enrollees age 60 years and younger, CMS allows local Medicare Administrative Contractors to determine whether to cover lumbar disc replacement surgery for this younger age group. If you are a Medicare enrollee 60 years or younger, check with your surgeon to see if this procedure would be covered for you.
Does any insurer cover multi-level lumbar ADR?
Some people have more than one damaged disc. In the past, only one disc could be replaced in the spine, but advances in technology and surgical techniques have enabled surgeons to replace multiple damaged discs.
However, no health insurance company currently covers multi-level lumbar disc replacement surgery as a policy. Your surgeon may be able to talk with your insurance company to make an exception, but until there are more studies with multi-level ADR, insurers will limit coverage to one level of the lumbar spine.
Lumbar artificial disc replacement is an alternative to lumbar fusion surgery for treating chronic pain in the lower back caused by a damaged spinal disc. Although several artificial disc devices for the lumbar spine are approved by the FDA
, not every health insurance company covers this procedure to date.
If you are considering lumbar disc replacement surgery, check with your insurer before scheduling a procedure. The staff at your spine surgeon’s office may also be able to determine if your insurance will cover this procedure for your case.
Updated: September 18, 2020