Before Medicare will pay for a knee replacement, you might need to try other options such as physical therapy, medication or assistive devices.
Here’s what you should know about qualifying for knee replacement surgery with Medicare.
What makes a knee replacement medically necessary?
There’s no single law or national policy that lays out what “medically necessary” means for Medicare’s coverage of knee replacements. You’ll need to work with your doctor to determine whether a knee replacement is medically necessary for you.
In general, these kinds of issues can make a knee replacement medically necessary:
Fractures in certain bones.
Malignant tumors or tissue death in and around the knee.
Failure of a previous osteotomy or knee replacement procedure.
Advanced joint disease in the knee that hasn’t been sufficiently helped by other more conservative interventions.
More conservative interventions include things like anti-inflammatory medications, physical therapy, assistive devices or therapeutic injections. You might be required to show that you’ve tried one or more of these options for several months — and your knee pain or loss of function has continued.
You might also need to get an X-ray or MRI as part of the process to determine medical necessity.
How much is knee replacement surgery on Medicare?
Your costs for a knee replacement depend on what kind of Medicare coverage you have and where you get the surgery.
Original Medicare (Part A and/or Part B)
If you get a knee replacement as a hospital inpatient, you’ll be covered by Medicare Part A. Once you’ve met your Medicare Part A deductible — $1,600 in 2023 — you wouldn’t owe any copays until you’ve been in the hospital for more than 60 days. (The median hospital stay after inpatient knee replacement surgery is three days.)
Outpatient knee replacement surgery is covered by Medicare Part B. Part B generally pays 80% of the allowed cost for covered procedures after you meet your annual deductible of $226 in 2023, so you would owe the remaining 20%.
Here are the average patient costs for total knee arthroplasty for people with Medicare Part B, according to Medicare.gov:
At a hospital outpatient department: $1,818.
At an ambulatory surgical center: $2,054.
Medicare Advantage (Part C)
Medicare Advantage plans must cover at least the same benefits as Medicare Part A and Part B, so they also cover medically necessary knee replacements.
Medicare Advantage plans are sold by private insurance companies, which set the out-of-pocket costs such as copays, coinsurance and deductibles for each plan.
If you have a Medicare Advantage plan, check with your insurance company to see what your costs would be for knee replacement. You might also have certain requirements to stay in-network for the procedure.
Medicare Advantage companies
Get more information below about some of the major Medicare Advantage companies. These insurance companies offer plans in most states. The plans you can choose from will depend on your ZIP code and county.
What Medicare covers
Medicare covers a lot of things — but not everything. Find out where Medicare stands in the following areas: