Is Scoliosis Treatment Covered by Insurance?

Scoliosis is a complex condition that can impact people of all ages, but navigating the insurance landscape for treatment can be equally challenging. If you or your child has been diagnosed with scoliosis, understanding your insurance coverage is a crucial first step in receiving the care you need. In this article I’ll help demystify the process and provide you with the knowledge to confidently manage your insurance claims.

Coverage for Diagnostic Tests

Insurance typically covers diagnostic tests for scoliosis, including X-rays, MRIs, and physical exams. These tests are essential to confirm the diagnosis and determine the severity of the curvature. To ensure coverage, these tests must often be deemed medically necessary by your provider. Some tests such as an MRI may require a preauthorization to be covered by insurance.

Pro Tip: Request preauthorization for diagnostic imaging to avoid unexpected expenses. At ScoliCare Denver, our team assists patients in securing the necessary approvals to streamline this process.

Coverage for Treatment

Insurance plans often cover a range of scoliosis treatments, but the extent of coverage can vary. Commonly covered treatments include:

• Physical Therapy: Many plans cover scoliosis-specific exercises like those offered through the ScoliBalance® program.  Scoliosis-specific exercises are billed to insurance using therapy codes.  The codes to check for coverage are :
  • 97110: Therapeutic Exercises
  • 97530: Therapeutic Activity
  • 97112: Neuromuscular Re-education
  • 97012:  Mechanical Traction
• Bracing: Custom scoliosis braces like ScoliBrace® are often covered by most insurance carriers.  They may require preauthorization and a letter of medical necessity. Ensure your plan includes durable medical equipment (DME) coverage by your provider.  Different types of scoliosis brace required different codes.  The most frequently used codes for billing rigid scoliosis braces such as the ScoliBrace are:  L0482 TLSO Brace, L1200 TLSO Brace, the codes for soft braces such as Spine Core are L1005, and codes for off-the-shelf braces such as the Aspen Peak Scoliosis brace is L1300.
• Surgical Intervention: In severe cases, spinal fusion surgery is typically covered, but requires thorough documentation of necessity.

Pre-authorizations

Preauthorization is a common requirement for scoliosis treatments. This process involves obtaining approval from your insurance provider before starting a treatment. Failing to secure preauthorization may result in denial of coverage.  In our experience exams, x-rays and physical therapy do not typically require pre-authorizations and scoliosis braces usually do.

How to Navigate Pre-authorizations:

1. Consult your provider to understand the documentation required.
2. Submit a detailed treatment plan to your insurer.
3. Follow up regularly to ensure timely approval.

At ScoliCare Denver, we provide letters of medical necessity and all the paperwork required for a pre-authorizations and insurance reimbursement.

In-Network Providers vs Out of Network Providers

Receiving treatment from in-network providers can significantly reduce out-of-pocket costs, however most scoliosis specialists (excluding surgeons), do not contract with insurance companies because of the low reimbursement rates. Insurance companies have agreements with in-network providers, offering discounted rates for services. Because insurance contacts can severely reduce reimbursements, many specialty clinics can not afford to contract with them. Always confirm your provider’s network status and ask for both in-network and out-of-network coverage and reimbursement rates.

What if My Provider is Out-of-Network?

Out-of-network care can lead to higher costs, but some plans may offer reimbursement. Check your policy details and consider discussing payment plans with the provider.

Coverage Limits and Exclusions

Insurance policies often include coverage limits or exclusions for certain scoliosis treatments. For example:

• Some plans may cap the number of physical therapy sessions covered annually.
• Experimental or alternative treatments may be excluded.
• Set rates per reimbursement.  Be sure to check your insurance coverage allowable for each service.  This is the amount your insurance will cover or allow for each service.  This is generally higher for out-of-network providers.

Understanding these limitations is key to avoiding unexpected expenses. Contact your insurer to clarify any ambiguous policy language.

Type of Provider

The type of provider administering your scoliosis treatment can impact coverage. Insurance plans often require treatment to be delivered by licensed professionals, such as:

• Orthopedic surgeons
• Chiropractors
• Physical therapists
• Certified orthotists for bracing
• Medical doctors

Additionally, some insurance plays reimburse different rates for different types of providers.  Choosing a provider with specialized training in scoliosis, like those at ScoliCare Denver, ensures both quality care and compliance with insurance requirements.

Appeals Process

If your insurance claim is denied, don’t lose hope. The appeals process allows you to challenge the decision and provide additional evidence supporting the medical necessity of your treatment.

Steps to Appeal a Denial:

1. Request a detailed explanation of the denial from your insurer.
2. Gather supporting documentation, such as medical records and provider recommendations.
3. Submit a formal appeal within the specified timeframe.

Our team at ScoliCare Denver can guide you through this process to improve your chances of a successful appeal.

Medicaid and Medicare

Medicaid and Medicare may cover surgeries for scoliosis, physical therapy and bracing, however outside of surgery most specialists do not contract with Medicaid or Medicare

• Medicaid: Coverage depends on the state but generally includes diagnostic tests, bracing, and surgery for children and adolescents with some clinics.
• Medicare: Covers diagnostic tests and necessary treatments for adults over 65 or those with qualifying disabilities, however as previously mentioned most specialists outside of surgeons do not accept medicare.

Coordination of Benefits

If you have multiple insurance policies, coordination of benefits determines which insurer pays first. For example, a child covered by both parents’ policies will have a primary insurer designated based on the “birthday rule” (the parent with the earlier birth date in the calendar year).

Ensure your providers are aware of all active policies to maximize your benefits.

Insurance and Age: Children, Adolescents, Young Adults, and Seniors

Insurance needs and coverage often vary by age group:

• Children and Adolescents: Pediatric scoliosis treatments, including bracing and physical therapy, are frequently covered if deemed medically necessary.
• Young Adults: Transitioning to adult care can sometimes disrupt coverage. Insurance coverage verification is recommended..
• Adults and Seniors: Coverage for degenerative scoliosis often focuses on pain management, physical therapy and bracing.  Surgery may be covered in severe cases that have failed conservative treatment.

Take Control of Your Scoliosis Care

Navigating insurance coverage for scoliosis treatment can feel overwhelming at ScoliCare Denver, we provide all the clinical information you need to check your insurance coverage.  Although it’s a nice benefit when your insurance pays for a portion of the treatment, ensuring you get the right treatment at the right time is the most important action step.  

ScoliCare is a world leader in education, research and the non-surgical treatment of scoliosis and hyperkyphosis.  For scoliosis treatment in Denver call 303-955-1919. To see if you are a candidate for our treatment request a free discovery call with a doctor by clinic on the link bellow or download our free ebook to learn more about treating scoliosis.