Covers spinal fusion via CMS national policy and contractor-specific LCDs. Some lumbar fusion CPTs (22551, 22612, 22633) are no longer on the Inpatient-Only List, meaning Medicare may pay them in HOPD or, in limited cases, ASC. Site-of-service review matters — placing a case in the wrong setting can trigger denial.

Each publishes its own spinal fusion medical policy. Most require documented failed conservative care — 6+ weeks of PT, NSAIDs, and injections — before approving fusion. Prior auth is mandatory. Denials are common and often reversed on appeal when documentation is clean.

A meaningful share of spine volume. Different rules per state, separate fee schedules, and longer payment cycles. Know your territory's workers' comp landscape before your first call.

Facility payment: Inpatient stays group to a spinal fusion MS-DRG (most commonly DRG 459, 460, or 471–473). HOPD cases group to an APC. Device cost almost always lives inside the DRG bundle — every dollar of implant cost erodes the hospital's contribution margin on a fixed payment. This is why hospitals scrutinize spine implant pricing so aggressively.

Physician payment: Paid under MPFS, driven by work RVUs. Add-on codes take a multiple-procedure reduction. Co-surgeon and assistant-surgeon modifiers (62, 80, 82) are common and frequently miscoded.

Pass-through C-codes: The exception, not the rule. New technology C-codes expire after 2–3 years. Know whether your product has one — it's a meaningful economic argument with hospital administrators.

Delta Dental, MetLife, Aetna Dental, Cigna Dental, Guardian, and others. Each negotiates a fee schedule with in-network providers. Annual maximums of $1,500–$3,000 cap what the plan will pay per patient per year — creating constant treatment-planning conversations around plan year boundaries.

Traditional Medicare does NOT cover routine dental. Medicare Advantage plans often offer limited dental coverage. Medicare may cover dental services integral to a covered medical procedure (e.g., dental clearance before cardiac surgery) — this is the cross-coding opportunity.

Implants, cosmetic dentistry, and out-of-network care are frequently fully out of pocket. Understanding this shapes how practices sell treatment plans — and how you position your product in the economics of their practice.

Fee schedules: Each insurer publishes a contracted fee per CDT code. In-network providers accept it as payment in full (less patient copay/coinsurance). Out-of-network providers may balance-bill the difference.

Annual maximums: The single biggest constraint in dental. A patient with a $1,500 annual max who needs a $4,000 crown + bridge sequence will pay $2,500 out of pocket or stage the work across plan years. Practices time treatment plans around this constantly.

Missing tooth clauses: Excludes coverage for replacement of any tooth lost before the patient enrolled in the plan. Catches implant cases constantly.

Implant economics: A single-tooth implant restoration (D6010 + abutment + crown) commonly bills $4,500–$7,000 total. Coverage varies wildly — some plans cover none, some cover only the crown. Cross-coding to medical, where applicable, recovers significantly more.

Pays for DME through four regional DME MACs (Jurisdictions A, B, C, D). Each MAC publishes its own LCDs and Local Coverage Articles (LCAs). The DME MAC for a beneficiary is determined by the patient's home address — not where the supplier is located. This geography matters for your accounts.

Medicare Advantage: Plans set their own networks and prior auth rules — often more restrictive than fee-for-service Medicare.

Medicaid: State-specific DME programs. Wheelchair coverage in Texas looks nothing like wheelchair coverage in California.

Commercial: Many follow Medicare LCDs as a baseline but add their own prior auth and frequency rules.

Purchase: Item shipped, claim submitted, payment made. Walkers, canes, glucose monitors, most prosthetics.

Rental: Monthly billing for as long as the item is medically needed. Continuous use — oxygen, certain ventilators.

Capped rental: Medicare pays a declining monthly rental for up to 13 months, then transfers ownership to the patient. Supplier remains responsible for service during the rental period. Each month requires its own modifier (KH → KI → KJ). Examples: CPAP, standard wheelchairs, hospital beds.

DMEPOS fee schedule: CMS publishes annually, with separate rural and non-rural rates. Commercial payers often anchor to this but negotiate variances.

• Standard Written Order (SWO) — beneficiary's name, item description, prescriber name/NPI, and date. Required before billing for nearly every DME item.
• Face-to-face evaluation — many items (power mobility, hospital beds, ventilators) require a face-to-face exam by the ordering practitioner within 6 months of the order.
• Certificate of Medical Necessity (CMN) — specific items (oxygen, certain wheelchairs, parenteral nutrition) require a completed CMN signed by the prescribing practitioner.
• Proof of delivery — signed delivery confirmation with date and patient signature. Audits look for this first.