How does health insurance cover spinal fusion?

See how Medicare and private health insurance cover spinal fusion.

You can get cover for a spinal fusion with Medicare and silver-rated private health hospital policies. Costs can vary greatly and you might encounter some out-of-pocket costs if you don't plan ahead.

What is a spinal fusion?

Spinal fusion is surgery which permanently connects two or more vertebrae in your spine, thereby stopping motion between them and reducing pain. During the operation, your surgeon places bone (or a bone-like material) between the space in the two spinal vertebrae. Metal plates are often used to hold the vertebrae together, so they can heal as one solid structure.

You might need spinal fusion for:

  • Spinal weaknesses. Your spine can become weak and unstable as a result of conditions such as severe arthritis in the spine or specific injuries.
  • Herniated disk. After the removal of a herniated disk, you might need a spinal fusion.
  • Spinal deformities. Spinal fusion is often used to treat spinal deformities such as scoliosis.

What does the surgery involve?

Spinal fusion surgery usually take between three and seven hours. You will be under general anaesthesia during the whole operation. The procedure may vary depending on the location of the vertebrae that need to be fused, as well as factors such as your general health and age. Your surgeon may remove a part of the spine that is compressing nerves. They will place the bone graft material between the two spinal vertebrae and use metal plates, known as internal fixation, to help fuse the vertebrae together.

Generally, you will need to stay in hospital for at least two days following the procedure. It's often the case that you will be in some pain afterwards. Pain medication is usually administered to alleviate any discomfort.

How does Australian health care treat spinal fusions?

Both Medicare and private health insurance cover spinal fusions. See how their costs compare below.

Public

With Medicare, you can find spinal surgery items within sub-group 17 (spinal surgery) of group T8 (surgical operations) on the Medical Benefits Schedule (MBS). Item numbers 51011 to 51171 cover various spinal surgery operations, including spinal fusions. Costs vary depending on the surgery and surgeon but for a rough guide, item number 51013 has a fee of $2,430.55 with a benefit of 75%, meaning you could be looking at around $607.60 out of pocket for surgery fees.

Keep in mind though that your doctor doesn't need to adhere to the MBS fee. You might also have out-of-pocket expenses for anaesthesia fees, consultations, nursing fees and hospital fees. In some cases, Medicare will cover most of the costs which means you'll have very little out-of-pocket expenses. In any case, ask your doctor about costs and check the MBS for the item number that is applicable to you.

Private

You should be able to find cover for spinal fusion with all silver tier hospital policies under back, neck and spine. Silver-rated hospital only policies usually cost around $25 to $30 a week. Most policies come with a 2-month waiting period so you are able to see a doctor quickly. The waiting period goes up to 12 months if you have a pre-existing spinal condition.

Hospital treatment with private health insurance for back, neck and spine usually covers the investigation and treatment of the back, neck and spinal column, including spinal fusion. This includes sciatica, prolapsed or herniated disc, spinal disc replacement and spine curvature disorders such as scoliosis, kyphosis and lordosis.

How to compare your options for private spinal fusion

Before you agree to a procedure, make sure your health provider will cover you. Ask them about potential out-of-pocket expenses, such as consultation and anaesthesia fees. Be sure to ask for the MBS item number from the surgeon as well. That way, you'll have a good idea of any out-of-pocket expenses.

Keep in mind that if you opt to receive treatment as a public patient in a public hospital, waiting times can vary significantly. If you're not considered at risk, you might be waiting a while for treatment in a public hospital. You will also be assigned a surgeon by the hospital. You can generally only choose when and who treats you if you go private. For a thorough comparison of costs and cover, check out the table below.

Brand Policy Benefit Excess Price Apply
ahm logo Lite Bronze Plus Back, neck, spine – Sciatica, prolapsed or herniated disc, spinal disc replacement and spine curvature disorders such as scoliosis, kyphosis and lordosis $500 $89.80 Go to Site
Medibank logo Bronze Plus Progress Back, neck, spine – Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion $500 $84.20 Go to Site
nib helath insurance logo Silver Hospital Back, neck and spinal column, including spinal fusion. $500 $106.56 Go to Site
nib helath insurance logo Silver Hospital Back, neck and spinal column, including spinal fusion $500 $109.24 Go to Site
HCF health insurance Silver Hospital Back, neck, spine – Sciatica, prolapsed or herniated disc, and spine curvature disorders such as scoliosis $500 $109.55 Go to Site

Prices are based on a single person in Sydney earning less than $90,000.

Other things to know if you need a spinal fusion

Before surgery

If you choose to go private, it's likely your health fund will have a No Gap scheme. Always ask the surgeon you use if they are participating in the scheme; this will keep out-of-pocket expenses to a minimum. Doctors' fees can vary significantly so it's smart to ask them about their fees before commencing treatment.

Because spinal fusion is a complex procedure, you may encounter out-of-pocket costs for an orthopaedic surgeon, specialist consultations, assistant surgeon, anaesthetist, pathologist and radiologist. Ask your health insurance provider about costs for these services before surgery.

After surgery

You will probably need rehabilitation after spinal surgery and your activities should be limited for the first 6 months. Every surgeon will have slightly different post-op care to adhere to so be sure to follow your surgeon's advice. You shouldn't bend past 90 degrees, lift anything heavy at all and avoid twisting your back as much as possible. Physiotherapy is often an important part of the recovery process as well. You won't be allowed to drive for at least 6 weeks after surgery.

Picture: GettyImages

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