Does Medicare Cover Knee Replacement Surgery?

Are you considering knee replacement surgery and wondering, “does Medicare cover knee replacement?” In most cases, Medicare does cover knee replacement surgeries, both inpatient and outpatient, ensuring relief from chronic knee pain for eligible beneficiaries. The extent of your coverage and the potential out-of-pocket expenses depend on your particular Medicare plan details.

This article delves into the specifics of how Medicare helps with knee replacement costs, what you might pay, and other key considerations for your surgery planning.


Key Takeaways

  • Medicare covers knee replacement surgery, with variations in coverage and out-of-pocket costs depending on whether the procedure is inpatient or outpatient, and the specifics of the individual’s Medicare plan.


  • The surgery must be deemed medically necessary to qualify for Medicare coverage, with documentation required to verify the need for the procedure based on severe pain or disability not improved by conservative treatments.


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Exploring Medicare Coverage for Knee Replacement Surgery

Medicare, the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease, indeed provides coverage for knee replacement surgery.

However, the amount covered and the out-of-pocket costs you may incur can vary depending on the specifics of your Medicare plan and whether you’re having inpatient or outpatient surgery.

Whether you opt for inpatient knee replacement surgery, which typically involves at least a one-night stay at the hospital, or outpatient surgery, where patients are discharged on the same day, the Medicare coverage you receive and the costs you incur will significantly depend on your choice to cover knee replacement surgery.


Exploring Medicare Coverage for Knee Replacement Surgery

Inpatient vs. Outpatient Knee Replacement

The main difference between inpatient and outpatient knee replacement lies in the location and duration of your recovery. Inpatient surgery typically involves a hospital stay, providing patients with immediate access to medical professionals during the initial recovery period.

In contrast, outpatient surgery often allows patients to return home the same day to recover in the comfort of their own surroundings, with follow-up care typically provided at a separate outpatient facility.

Medicare provides coverage for specific costs associated with your stay, irrespective of the procedure being inpatient or at a hospital outpatient department. However, bear in mind that inpatient costs are typically higher due to the extended hospital stay, hence, the exact costs can vary.


Coverage Specifics Under Medicare Part A and Part B

Medicare Part A, often referred to as hospital insurance, covers inpatient hospital care, hospital stays, meals, nursing care, and medications received as part of inpatient treatment. It is essential to have medical insurance like Medicare to ensure access to these services.



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Therefore, if you opt for inpatient knee replacement surgery, Medicare Part A would come into play.

On the other hand, Medicare Part B covers outpatient care. If you have outpatient knee replacement surgery or need post-surgery outpatient rehabilitation services, Medicare Part B will shoulder these costs, which include necessary doctor visits and physical therapy sessions.


Navigating Medicare Advantage Plan Coverage

Medicare Advantage plans, also known as Medicare Part C, offer an alternative way to receive your Medicare benefits. These plans are offered by private insurance companies approved by Medicare and often include coverage for services not covered by Original Medicare, such as:


  • Prescription drugs
  • Routine dental care
  • Vision care
  • Hearing aids
  • Fitness programs


If you’re enrolled in a Medicare Advantage plan, you’ll be glad to know that these plans also cover knee replacement surgeries.

However, out-of-pocket costs and benefits can vary depending on the specifics of your plan. Therefore, before you undergo surgery, comprehending your plan’s coverage details in full is of utmost importance.

The Path to a Medically Necessary Knee Replacement

While Medicare coverage can significantly ease the financial burden of knee replacement surgery, it’s important to remember that not all knee replacements qualify for Medicare coverage.


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The surgery must be deemed knee replacement medically necessary by a healthcare provider. This usually means that you’ve been suffering from severe knee pain or disability that has not improved with conservative treatments like physical therapy or medications.

Having a thorough discussion about your symptoms and treatment history with your healthcare provider is vital to determine if knee replacement is the most suitable course of action for you. The decision should be based on a thorough evaluation of your overall health, the severity of your knee condition, and the impact of your symptoms on your quality of life.


Identifying Qualifying Conditions for Knee Replacement

The qualifying conditions for knee replacement surgery encompass severe pain, challenges with walking, and experiencing knee pain even at rest. If you’re finding it difficult to perform everyday activities due to knee pain, or if your pain persists even while resting, you might be a candidate for knee replacement surgery.

However, severe knee pain alone may not be enough to qualify for knee replacement surgery. Medicare also considers other factors such as:


  • Knee stiffness
  • Arthrofibrosis
  • Destructive conditions that hinder employment or functional activities
  • Disabling pain or functional disability
  • Progressive and substantial bone loss
  • Fracture or dislocation of the patella
  • Infection


Documentation and Approval Process

Once your healthcare provider has determined that knee replacement surgery is medically necessary, you will need to go through the documentation and approval process for the knee replacement procedure. This process necessitates working closely with your physician and their billing team to compile the necessary information and paperwork.

The necessary documentation for Medicare approval comprises physician certification of medical necessity for admission, if applicable, and a legible, detailed procedure note or report. Collaborating closely with your healthcare provider to ensure that all documentation aligns with Medicare’s requirements will help streamline this process and minimize the risk of coverage denials.

Understanding Out-of-Pocket Costs for Knee Replacements

Although Medicare covers a significant portion of the costs associated with knee replacement surgery, it’s not all-inclusive. You will likely need to pay some out-of-pocket costs, including deductibles and coinsurance, which vary depending on your specific Medicare plan.


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Comprehending these out-of-pocket costs is essential for effective budgeting and financial planning. You’ll want to factor in the costs for both the surgery itself and any necessary post-surgery care. This can include:


  • Prescription medications
  • Follow-up doctor visits
  • Physical therapy sessions
  • Any necessary durable medical equipment.


Deductibles and Coinsurance

Before Medicare coverage comes into effect, you may need to pay two types of out-of-pocket costs – deductibles and coinsurance. A deductible is the amount you must pay for your health care or prescriptions before Medicare starts to pay its share. Coinsurance, on the other hand, is your share of the costs for a service after you’ve paid your deductible.

The exact amounts for your deductibles and coinsurance can vary depending on the specifics of your Medicare plan. For instance, under Medicare Part B, after you meet your yearly deductible, you’ll typically pay 20% of the Medicare-approved amount for most doctor services, including knee replacement surgery.


Additional Costs Beyond Medicare Coverage

In addition to deductibles and coinsurance, there may be additional knee replacement costs associated with your knee replacement surgery that Medicare cover knee replacement does not fully address. These can include prescription medications, stays in skilled nursing facilities, and other post-surgery care.

These additional costs can be substantial, necessitating adequate planning. If you have prescription drug coverage under Medicare Part D, be sure to check with your plan to see what your costs may be for any medications prescribed after surgery.

Similarly, if you think you may need to stay in a skilled nursing facility following surgery, check with your plan to understand what costs you may be responsible for.

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Post-Knee Replacement Care and Medicare Benefits

Following knee replacement surgery, post-operative care is crucial to ensure a successful recovery. This typically includes physical therapy and rehabilitation services to strengthen the knee and restore mobility, as well as the use of durable medical equipment (DME) to aid in movement and support healing.

Thankfully, Medicare offers coverage for many of these post-operative care services. Depending on the details of your plan, you may have coverage for physical therapy sessions, follow-up doctor visits, and necessary DME such as walkers or canes.


Physical Therapy and Rehabilitation Services

Physical therapy and rehabilitation services are essential components of recovery following knee replacement surgery. These services typically involve exercises to strengthen the knee and improve flexibility and range of motion, which are crucial for restoring normal movement and function.


Medicare criteria for total knee replacement



Physical therapy and rehabilitation services, deemed medically necessary by your healthcare provider, generally fall under the coverage of Medicare Part B. This includes necessary doctor visits and physical therapy sessions.

However, there are no specific limits on the number of sessions Medicare will cover in a calendar year, but additional documentation may be necessary for costs exceeding a certain threshold.


Durable Medical Equipment (DME) Support

Durable Medical Equipment (DME) is designed for repeated use and assists with daily activities. Following knee replacement surgery, DME such as walkers, wheelchairs, or crutches can be crucial to aid in mobility and provide stability during the initial recovery period.

Medicare Part B covers DME that is deemed medically necessary and prescribed by a healthcare provider. However, the specific cost-sharing responsibilities for DME under Medicare Part B can differ depending on the particular item and the supplier involved. Hence, it’s crucial to check with your Medicare plan for details regarding coverage for DME.

Alternatives and Complementary Treatments Covered by Medicare

Although knee replacement surgery can considerably enhance the quality of life for individuals with severe knee pain, it isn’t the sole solution. Medicare also covers a range of alternative and complementary treatments that can help manage knee pain and potentially delay or even avoid the need for surgery.


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These alternative treatments include conservative pain management options like arthritis medication and physical therapy, as well as preventative measures such as weight loss and exercise programs. Such treatments can often be beneficial in managing mild to moderate knee pain and can play a crucial role in overall knee health.


Conservative Pain Management Options

Conservative pain management options for knee pain include:


  • Physical therapy
  • Medications (such as nonsteroidal anti-inflammatory drugs)
  • Corticosteroid injections
  • Platelet-rich plasma (PRP) therapy
  • Knee braces or supports
  • Assistive devices (such as crutches or canes)
  • Weight loss and exercise


These treatments aim to manage pain and improve function without resorting to surgery, making them an attractive option for those with mild to moderate knee pain or those who may not be candidates for surgery.

Medicare extends coverage for numerous conservative pain management options, such as arthritis medications and physical therapy. Arthritis medications can help reduce inflammation and alleviate pain, while physical therapy can improve strength, flexibility, and mobility. Both treatments can play a crucial role in managing knee pain and improving overall quality of life.


Preventative Measures and Early Interventions

Maintaining knee health and potentially circumventing the need for knee replacement surgery heavily depends on preventative measures and early interventions. These measures include lifestyle changes such as weight loss and exercise programs, both of which can significantly improve knee pain and function.

Weight loss can reduce the strain on your knees, helping to alleviate pain and prevent further damage, while exercise can strengthen the muscles around the knee, improving stability and reducing the risk of injury. Medicare provides coverage for obesity counseling and weight loss programs, making these treatments accessible for many beneficiaries.


In conclusion, while knee replacement surgery can be a highly effective treatment for severe knee pain, it’s not the only option available. Medicare provides coverage for a range of treatments, including conservative pain management options and preventative measures, as well as the surgery itself.

However, it’s important to understand that coverage can vary depending on the specifics of your Medicare plan, and you may still be responsible for some out-of-pocket costs. Always consult with your healthcare provider to discuss the best treatment options for your knee pain and to understand the costs involved.

Frequently Asked Questions



What is the average cost of a knee replacement?

The average cost of a knee replacement surgery (with no complications) is approximately $29,300, with prices ranging from $15,000 to $70,000.


Why would insurance deny a knee replacement?

Insurance may deny a knee replacement if they deem the services as not medically necessary, no longer appropriate in a specific healthcare setting, or if the effectiveness of the treatment has not been proven. Always consult with your doctor and insurance provider for further clarification.


How do you qualify for a knee replacement?

You may qualify for a knee replacement if you have severe pain, swelling, and reduced mobility in your knee, and if the pain interferes with your quality of life and daily activities. Consider discussing your symptoms with a healthcare professional to determine if you are a candidate for the surgery.


Does Medicare cover knee replacement surgery?

Yes, Medicare does cover knee replacement surgery under both Part A and Part B, but the coverage amount and out-of-pocket costs can vary based on your specific Medicare plan and whether the surgery is inpatient or outpatient.


What out-of-pocket costs can I expect for knee replacement surgery under Medicare?

You can expect out-of-pocket costs for knee replacement surgery under Medicare to include deductibles, coinsurance, and potential expenses for prescription medications and post-surgery care, which vary depending on your Medicare plan.

Consider discussing these details with your healthcare provider and Medicare representative to better understand your individual costs.

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.