Medicare covers total knee replacement surgery if the doctor deems it’s medically necessary. Medicare will also provide coverage for alternative treatments for knee replacement outside of surgery. The Medicare-covered alternative to knee replacements could include therapy, injections, or Durable Medical Equipment. Medicare may cover other knee replacement alternatives. Here we discuss surgery & alternative treatments for knee replacement surgery that’s covered under Medicare.
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Does Medicare Cover Total Knee Replacements?
Yes, Medicare does cover total knee replacements. Total knee replacement surgery is usually an inpatient procedure. Inpatient procedures are covered under Part A.
There are some occasions for a patient may receive total knee placement surgery as an outpatient. In this case, you’ll have coverage under Part B.
How Much Will Medicare Pay for Total Knee Replacement?
If it’s an inpatient surgery, Medicare will cover most of the cost. You’ll be responsible for the Part A deductible, as well as additional cost-sharing in the form of coinsurance. If it’s an outpatient surgery, Medicare will cover 80% of the cost.
You’ll be responsible for the Part B deductible and 20% of the cost. Any prescriptions given at the hospital will also be covered under Part B. Any prescriptions that you’re prescribed to take at home won’t have coverage unless you have a stand-alone Part D plan. Or, if you have an Advantage plan that covered prescriptions.
If you have a Medigap plan, depending on the letter plan you enrolled in, you could have zero out of pocket costs for total knee replacement surgery. If you have a Medicare Advantage plan, you’ll have to check with the carrier you enrolled with to determine what you’ll have to pay out of pocket.
Alternative Knee Replacement Treatments Covered by Medicare
Medicare does cover many alternative treatment options for those that prefer a more conservative route than total knee replacement surgery. We’ll go over them below.
Does Medicare Pay for Knee Gel Injections?
Yes, Medicare will cover knee injections that approved by the FDA. This includes hyaluronan injections. Medicare does require that the doctor took x-rays to show osteoarthritis in the knee.
The coverage is good for one injection every 6 months. Hyaluronan is Hyaluronic Acid, it’s naturally occurring in the body. While this solution may not be best for everyone, it should be something to consider before resorting to a knee-replacement. This treatment is also called Viscosupplementation.
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Is Coolief Covered By Medicare?
Medicare should cover Coolief treatment. Although, we recommend confirming with your doctor and insurance provider. This method of treatment doesn’t require any incision, no overnight hospital stay, and pain relief can last up to 12 months.
Most patients report an increase in mobility. In the Coolief clinical study, they found the treatment was longer-lasting and gave greater pain relief than the steroid injections. However, there are risks to all medical procedures; discussing your options with your doctor is very important.
Does Medicare Cover Synvisc Injections?
As far as Synvisc goes, this is an out-of-pocket procedure. The FDA hasn’t given approval for the treatments for interventional pain management.
Synvisc-One injections might not have Medicare coverage, even with a doctor’s request. Of course, Medicare does offer reimbursement for Synvisc-One and SYNVISC.
Does Medicare Cover Hyalgan Injections?
Hyalgan injections are another brand name like Synvisc; coverage for Hyalgan is available through many insurance plans, including Medicare. Since it’s given in the doctors’ office and the doctor administrates the injection, coverage is under Medicare Part B.
Does Medicare Cover Orthovisc Injections?
Unfortunately, Medicare does not cover Orthovisc injections.
Does Medicare Cover Euflexxa Injections?
As long as you have Part B, you have Medicare coverage for Euflexxa injections. If you have knee pain in both knees, bilateral OsteoArthritis, you may be eligible to receive injections in both knees.
Does Medicare Cover Rooster Comb Injections?
This treatment method only has FDA approval for the knees. Although, studies are underway for this to treat other joints such as the hip, shoulder, and elbows. Treatment with this method is Viscosupplementation.
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It’s when the knee is bone on bone, a natural supplementation from a rooster’s comb, hyaluronic acid injections provide cushioning. It acts like a lubricant preventing the bones from rubbing together and in turn decreases pain. These injections can prevent or at least prolong knee replacement. Most patients experience pain relief for about 6 months.
Does Medicare Cover iovera° Treatment?
Receiving Medicare coverage for iovera° will depend on your circumstances. Your physician can help you create a proper care plan.
It’s possible that Medicare will approve coverage if eligible. Pain Management services in an outpatient setting generally have coverage under Part B.
Is There a Medicare Knee Replacement Age Limit?
No, there is no age limit placed by Medicare for knee replacements. The majority of patients undergoing knee replacement are between 50 and 80 years old. Of course, you must be eligible for Medicare due to age or disability before receiving coverage.
Does Medicare Cover Genicular Nerve Block?
If other more conservative treatments have been unsuccessful, then Medicare will approve coverage for a Genicular nerve block. Genicular nerve blocks are investigational and not medically necessary. A diagnostic procedure; a professional injects a local anesthetic around the genicular nerves (nerves that transmit pain affecting the knee).
If the patient receives temporary relief they’re a candidate for Genicular Nerve Ablation. This procedure is therapeutical with a local anesthetic and cortisone mixture that can provide longer-lasting relief.
Genicular Nerve Ablation is also investigational and not medically necessary. Patients that have successful results with a genicular nerve block become candidates for genicular nerve ablation. The ablation cauterizes the genicular nerves which cause the pain; this provides anywhere from 6-12 months worth of pain relief before the nerve regenerates.
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How to Get Additional Coverage for Knee Replacement Surgery Under Medicare
Medigap works with your Medicare; so, if Medicare approves the service, the Medigap plan approves. When preparing for a surgery or procedure always consider recovery time; you may need help with daily activities for a few days no matter which option you choose. Since Medicare only covers outpatient procedures at 80%, Medicare beneficiaries pay 20%.
By obtaining a Medicare Supplement plan you can have coverage for the coinsurance, copayments, and deductibles. If you know you will need a total knee replacement or are looking into alternative options, give us a call. We can help you get more out of pocket costs covered with your Medicare benefits. You can also compare options in your area by filling out our comparison form.
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Mr Esch,
I was looking at the PRP injection to see if i could possibly get it through Medicare. Found out that it’s not covered. Can i ask why?
Ive had 1 cortisone shot in my knee and it worked ok for about a month and a half. since then ive been dealing with the pain until last week when working on a project and i must have twisted the wrong way and, well lets put it like this the language that came out of my mouth was not proper, but at that time i didnt care. I went to my doctor the first day and the first thing out of his mought after i had gotten xrays was ( we can do 3 things)
1. you can have a knee replacement
2.i can remove the sist on the back of your knee
3 i can give you a cortisone shot
Well i took the shot option. However since then ive read up on the different shots available. except medicare wont pay fpr the PRP one. why? They figure ill live to long after it?
Hi Vincent, according to CMS: Medicare covers autologous platelet-rich plasma (PRP) injections only for patients who have chronic non-healing diabetic, pressure, and/or venous wounds only when the patient is enrolled in a clinical research study. This is because the drug is not yet FDA approved to be used for treatment. Medicare (and most other insurances) will only cover FDA approved treatments and medications.
I am scheduled for knee replacement About how much will out of pocket will be needed before surgery if I have Medicare ? 80 20
Cindy, if you only have Original Medicare (Part A and Part B) then you will be responsible for the Part A deductible (if inpatient), the Part B deductible (if applicable) and then 20% of the remaining costs.
I was diagnosed with severe OA in my hips and spine in 2014. Knees are not far behind, but I have lost weight, exercised, watched my diet, take Zn, Mg, etc. to avoid surgery. I don’t need pain meds nor crutches yet, and am now 68. Are there any Medicare Advantage plans that are better than others with guiding those like me who want to prevent joint replacements for another 10 years?
Hi Richard – the Advantage plans available to you vary by ZIP Code. You should speak to an agent about finding the best Medicare option for you.
Does Medicare cover minimally invasive knee surgery?
Hi Will – Medicare should cover it your doctor says it is medically necessary. However, minimally invasive procedures are often considered experimental and do not receive coverage.
My last synvisc one injection in March 2021 was not covered by Medicare. My previous ones always were. Did coverage change?
Hi Michael! What coverage do you currently have?
How hard and fast it the medicare rule for the 6 month intervals? For example: if I had a knee injection December 16, do I have to wait until June 16 or is the month of June close enough?
Hi Deb! You would have to wait untill June 16th, but I would confirm with your doctors’ billing department. They would no more on the subject.
I had received gel injections for my knees, it required 3 shots, now I see only one shot is given is that the same amount as a three shot? Do you still pay for the cocks comb shot or only the generic
Is the rooster comb injection covered under the BCBS Medicare Advantage Plan (Choice) . I am unable to locate it in my documentation. My therapist has suggested that I have this done. Please advise. Thanks.
Hi Bruce! Each Medicare Advantage carrier has its own summary of benefits. There is no way we would be able to see if rooster comb injections are covered. You would have to contact BCBS directly.
Knee unloader braces for osteoarthritis. Are they covered and what if any criteria need to be fulfilled to guarantee coverage? Thank you
Hi Richard! Knee unloader braces would fall under durable medical equipment. Part B covers DME as long as your doctors find it medically necessary. Your doctor would just need to write a prescription for the brace that you would submit to the DME provider. Part B will cover 80% of the cost. If you have a Medigap plan, it will cover the remaining 20%. If you have a Medicare Advantage plan, coverage varies. You would need to contact your carrier to see if knee unloader braces are covered or not. We have a great list of Medicare-approved braces and devices that may help answer any questions you have.
Medicare would not cover my Synvisc One Injections. I submitted them and they were rejected. Also my policy through Blue Cross (Anthem) would not cover them either. Someone has it wrong. What is going on?
Hi Ralph! Generally, Medicare considers Synvisc-One to be medically necessary when the patient has documented knee pain due to OA and has failed to respond to nonsteroidal anti-inflammatory drugs (NSAIDs) or other conservative therapies.