Authors
Evan J Mizerak, Jay Karri, David A Provenzano, Lisa Goudman, Ryan S D'Souza
Published in
Pain medicine (Malden, Mass.). Oct 19, 2026. Epub Oct 19, 2026.
Abstract
Spinal cord stimulation (SCS) is an important modality for treating chronic pain in patients who have failed conservative therapy and a substantial portion of the population rely on fee-for-service Medicare or Medicaid for coverage. We aimed to determine physician professional fee reimbursement rates and the ratio of Medicaid to Medicare professional fee reimbursement (MMI) for three common Current Procedural Terminology (CPT) codes related to SCS therapy (63650, 63685, and 63655) across states. Secondarily, we explored trends in utilization and reimbursement of these procedures by Medicare at the national level between 2013 and 2023.
Medicaid professional fee reimbursement data were extracted from publicly available fee schedules where available for individual states, while Medicare reimbursement data were extracted from the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Baseline and wage-adjusted MMI values were calculated for each state.
Medicaid reimbursed 11.5-21.0% less than Medicare across the evaluated CPT codes after wage adjustment, with differences of 11.8% for CPT 63650 (facility), 18.0% for CPT 63650 (non-facility), 11.5% for CPT 63685 (facility), and 21.0% for CPT 63655 (facility). Medicaid MMI values ranged from 0.397-1.87 across codes and settings. State-level Medicaid professional fee reimbursement varied substantially, ranging from $194.52-$639.38 for CPT 63650 (facility), $978.72-$2,781.65 for CPT 63650 (non-facility), $160.82-$558.00 for CPT 63685 (facility), and $375.97-$1,045.15 for CPT 63655 (facility); Medicare reimbursement was substantially less variable. From 2013-2023, Medicare utilization, rendering providers, beneficiaries, and standardized payments generally increased, although trends varied by CPT code and site of service.
Medicare physician professional fee reimbursement largely exceeds Medicaid physician professional fee reimbursement for three of the most common SCS procedural codes, suggesting potential access barriers to chronic pain procedures. Medicaid reimbursement shows considerable variation across states and among procedural codes, suggesting substantial interstate heterogeneity in Medicaid rate-setting that may reflect differences in state policy priorities or other factors not analyzed in this study.
PMID:
42895296
Bibliographic data and abstract were imported from PubMed on 19 Oct 2026.
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