Navigating Insurance for Pain Management: A Patient Guide
Insurance coverage for pain management can be confusing. Procedures that are medically necessary and well-supported by evidence are sometimes denied initially, while other procedures may require specific documentation before they're approved. Here's what you need to know.
What Insurance Generally Covers
Medicare and most commercial insurance plans typically cover:
- Epidural steroid injections (lumbar, cervical, thoracic)
- Nerve root blocks (diagnostic and therapeutic)
- Medial branch blocks and facet joint injections
- Radiofrequency ablation (following positive medial branch blocks)
- Spinal cord stimulator trials and implants
- Intrathecal drug delivery pump implants
- MILD procedure (Medicare specifically)
- Vertiflex spacer (Medicare specifically)
- Intracept procedure (Medicare; commercial varies)
- Nerve blocks (occipital, stellate ganglion, sympathetic, etc.)
- Joint injections (knee, hip, shoulder) when medically necessary
Prior Authorization
Many interventional procedures require prior authorization — insurance company review of the proposed procedure against established criteria before approval. This process typically takes 5–10 business days.
Dr. Rubin's office handles prior authorization for all covered procedures. We submit the necessary clinical documentation to your insurance company. You don't have to navigate this process yourself.
When Procedures Are Denied
Initial denials are common — and frequently successfully appealed. Common reasons for denial:
- Insufficient documentation of conservative treatment failure
- Incorrect diagnostic coding
- Criteria not met in the initial submission
We will appeal denied authorizations with additional clinical documentation as appropriate. Most medically appropriate procedures are eventually approved.
Self-Pay Procedures
Some treatments are not covered by insurance and are self-pay:
- PRP therapy for musculoskeletal conditions
- Ketamine infusions for chronic pain
- High-power laser therapy
- Low dose naltrexone (compounded medication)
- Regenerative injections for cosmetic or non-covered indications
We will always tell you upfront what to expect with your specific insurance and what the self-pay cost is if not covered.
Insurance We Accept
Dr. Rubin accepts Medicare, Aetna, Cigna, Empire Blue Cross Blue Shield, BCBS Anthem, HealthNet, HIP, Humana Medicare, Local 1199 PPO, Magnacare, MultiPlan/PHCS PPO, NYS Empire Plan, Oxford, United Empire, United Healthcare, HGI, and many others.
Call 516-492-3100 and our billing staff will verify your specific coverage before your appointment.