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Does Medicare Cover Knee Replacement?

Based on your medical records, history, and failed non-surgical treatments Medicare may cover 80% of your knee replacement cost.

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Doctors perform nearly 800,000 knee replacements each year in the U.S. The Centers for Disease Control and Prevention (CDC) reports higher rates of total knee replacement for Americans ages 65 and older.

Even if Medicare does cover your knee replacement, it could cost you thousands of dollars out-of-pocket .

Fortunately, the right Medicare Supplement, or Medigap plan, can help pay your knee replacement costs. Rather than paying thousands of dollars out-of-pocket for knee replacement surgery, you may be able to pay a monthly Medigap premium. Let’s find out how!

How Do You Avoid Denial of Claim for Knee Replacement?

To avoid denial of knee replacement claims, your medical records must document medical necessity.

A patient’s medical history should include the following :

  • A detailed description of the pain

  • Limitations of specific activities of daily living

  • Safety issues

  • Contraindications to non-surgical treatments

Examples of failed non-surgical treatments may include:

  • Medications

  • Weight loss

  • Physical therapy

  • Occupational therapy

  • Intra-articular injections

  • Braces, orthotics or assistive devices

  • Home exercise plans

  • Assistive devices (such as cane, walker, etc.)

In addition to the above patient medical history, records must document a doctor’s physical findings. Descriptions of physical findings may include:

  • Deformity

  • Loss of range of motion

  • Crepitus (grating sound between bone and cartilage)

  • Effusions (fluid around the knee)

  • Tenderness

  • Gait description

Investigations should include test results, like X-rays and other imaging records. A statement of clinical judgment may be included.

What Does Knee Replacement Surgery Cost With Medicare?

Your Medicare knee replacement surgery costs depend on the services you need, whether you are an outpatient or inpatient, and your Medicare health plan.

According to national averages , Medicare patients typically pay more for total knee arthroplasty in ambulatory surgical centers ($2,054) than in hospital outpatient departments ($1,818).

Your Medicare surgery costs depend on your hospital status . To become a hospital inpatient, your doctor must write an order of admission, and the hospital must formally admit you. In this case, you may pay the Part A hospital deductible of $1,556 in 2022. Otherwise, you may pay the Part B outpatient deductible of $170.10 in 2022.

You are also responsible for paying your coinsurance and copayments. Original Medicare may only cover 80%, so you’ll pay the remaining 20% coinsurance. 

Instead of paying thousands of out-of-pocket costs, call the licensed agents at Senior Healthcare Direct at 1-833-463-3262, TTY 711, or click here to get your quote.

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LEGAL DISCLAIMER: The above is meant to be strictly educational and not intended to provide medical advice or solicit the sales of an insurance product or service of any kind.