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Does Original Medicare cover knee replacement surgery?
Knee replacement surgery is an increasingly common medical procedure, with the American Academy of Orthopaedic Surgeons estimating the number of total knee replacements performed annually to reach 3.5 million by 2030. If you need a knee replacement, you probably have many questions about the surgery, including whether or not it will be covered by Original Medicare.
Original Medicare (Parts A and B) will cover knee replacement surgery if it’s ordered by your doctor as a medically necessary treatment. Medicare Part A will cover it if it’s an inpatient procedure, and Medicare Part B will cover it if it’s outpatient. Medicare Advantage plans will also cover medically necessary knee replacements, as they offer the same benefits as Original Medicare. Let’s walk through the qualifications for a medically necessary knee replacement, the costs associated with the surgery and rules for Medicare coverage for services related to your recovery.
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What are the costs associated with knee replacement surgery?
Out-of-pocket costs for knee replacement surgery will vary depending on many factors, like the surgeon performing the procedure, the location, pre- and post-op testing and care, the cost of any surgical hardware and the severity of damage to the knee that needs the replacement. The Journal of Orthopaedic Surgery and Research estimates that the average cost of knee replacement surgery is $29,300.
Even if your knee replacement surgery is covered by Original Medicare, coinsurance and deductibles still apply. In 2023, the Medicare Part A deductible is $1,600 per benefit period, while the Medicare Part B deductible is $226 per year. After you’ve met your deductible, you’ll pay 20% of the Original Medicare-approved amount for the surgery, while Original Medicare will cover the remaining 80%.
When is knee replacement medically necessary?
There’s specific criteria used to determine whether a knee replacement is medically necessary. In most cases, the knee joint must be worn or damaged to the point of reduced mobility or significant pain, even when you’re at rest. Doctors will order knee replacement surgery when other interventions, like weight loss, pain medication, cortisone shots or walking assistance devices, are no longer providing relief. The symptoms also must be severely affecting your quality of life, and the benefits of the surgery must outweigh any risks.
Does Original Medicare cover physical therapy after surgery?
After your knee replacement surgery, you may need physical therapy to support your recovery. Medicare Part A will cover inpatient physical therapy in the hospital or skilled nursing facility after a hospital stay, while Medicare Part B will cover medically necessary outpatient physical therapy. Because Medicare Advantage plans offer the same benefits as Original Medicare, these plans may also help cover physical therapy after surgery, but details will vary by plan.
SelectQuote can help you understand Medicare Plan coverage for knee replacement surgery.
Finding the right Medicare plan can be difficult to do on your own, especially if you need coverage for a specific treatment like knee replacement surgery. Our licensed insurance agents can work with you to navigate the complexities of Medicare plans, finding you a Medicare Advantage plan for your unique needs and situation. We can quickly and easily shop plans on your behalf, saving you time so you can focus on getting the care you need.
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