Insurance Coverage for Bone Cement in Spinal Fractures

Is bone cement covered by health insurance?

Due to a family member being diagnosed with a compression fracture of the 12th vertebra, which has resulted in that vertebra being shorter and also having osteoporosis, the doctor did not inform us whether health insurance would cover the costs.
We were told that we would need to pay out of pocket for high-concentration low-temperature bone cement, which costs over 80,000 NTD, and for two jacks, which cost over 200,000 NTD.
The jacks are intended to improve kyphosis, and my family member has a kyphosis angle of over 30 degrees.
Is there a need to use the jacks? What is the effectiveness of this treatment? Is it significant or not very noticeable? I found that bone cement might be eligible for health insurance reimbursement, but it requires approval.
How long does the approval process typically take? Could you please help me with these questions? Thank you.

Steven, 40~49 year old female. Ask Date: 2023/04/23

Dr. Wang Shouji reply Orthopedics

Hello, the vertebral body jack procedure is not covered by health insurance.
Generally, bone cement mainly serves to stabilize the fracture site, and to achieve pain relief, it may be necessary to correct the shape, which might still require elevating the fracture site.
Changhua Hospital cares about your health.
Dr.
Wang Shou-ji.

Reply Date: 2023/04/23

More Info

When it comes to understanding insurance coverage for bone cement in spinal fractures, particularly in the case of a compression fracture at the T12 vertebra, there are several important factors to consider.
Firstly, bone cement, often referred to as vertebroplasty or kyphoplasty, is a minimally invasive procedure used to treat vertebral compression fractures. This procedure involves injecting a special type of cement into the fractured vertebra to stabilize it and alleviate pain. In many cases, insurance coverage for this procedure can vary based on the specific circumstances of the patient, the severity of the fracture, and the overall health condition of the patient.

In the United States, Medicare and many private insurance plans may cover vertebroplasty or kyphoplasty if certain criteria are met. These criteria typically include evidence of a recent vertebral compression fracture, significant pain that limits daily activities, and failure to respond to conservative treatments such as pain medication or physical therapy. However, the approval process often requires thorough documentation from the treating physician, including imaging studies and a detailed medical history.

Regarding the approval process for insurance coverage, it can take anywhere from a few days to several weeks. The physician's office usually submits a pre-authorization request to the insurance company, which then reviews the case based on established medical guidelines. If approved, the insurance will cover a portion of the procedure, but patients may still be responsible for co-pays or deductibles.

In your case, since your family member has osteoporosis and has been diagnosed with a compression fracture at T12, it is essential to discuss the specifics with the treating physician. They can provide guidance on whether vertebroplasty or kyphoplasty is appropriate and whether it meets the criteria for insurance coverage. Additionally, they can assist in submitting the necessary documentation to the insurance company for pre-approval.

As for the use of a "jack," or a device to improve posture and reduce kyphosis, this is often considered in conjunction with surgical interventions. The effectiveness of such devices can vary widely among individuals. While some patients may experience significant improvement in their posture and reduction in pain, others may find the results to be minimal. It is crucial to have a candid discussion with the healthcare provider about the potential benefits and limitations of using a jack for kyphosis correction.

In summary, it is advisable to:
1. Consult with the treating physician about the appropriateness of vertebroplasty or kyphoplasty for the compression fracture and the potential for insurance coverage.

2. Inquire about the pre-authorization process and what documentation is needed for insurance approval.

3. Discuss the use of a jack for improving kyphosis, including its potential benefits and limitations.

By taking these steps, you can better navigate the complexities of insurance coverage and treatment options for your family member's spinal condition.

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