Why 30% of Insurance Plans Don't Cover Gel Injections (And What You Can Do)

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The Surprising Coverage Gap

Insurance coverage for gel injections (hyaluronic acid or viscosupplementation) isn’t what most patients expect. You might assume that a treatment approved by the FDA and covered by Medicare would be available through your private insurance. Unfortunately, that’s not always the case.

Approximately 17 major private insurers—covering roughly 64 million lives—have decided not to cover hyaluronic acid injections for knee osteoarthritis. That represents nearly 30% of the privately insured population in the United States.

The practical impact is significant. Without coverage, a typical three-injection course of gel injections costs $1,600 or more out of pocket. Compare that to roughly $320 with Medicare coverage—an 80% difference in cost based solely on which insurance card you carry.

This coverage gap creates a frustrating situation: a treatment that could help you manage pain and potentially delay knee replacement surgery may be financially out of reach, even though you’re paying insurance premiums every month.

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Why Insurers Deny Coverage

Understanding why your insurer might deny coverage can help you challenge that decision. Most denials stem from one source: outdated clinical guidelines.

The AAOS 2013 Guidelines

In 2013, the American Academy of Orthopaedic Surgeons (AAOS) issued a guideline giving hyaluronic acid injections a “strong recommendation against” for knee osteoarthritis. Many insurers latched onto this guideline and built their coverage policies around it.

The problem? That guideline is now over a decade old, and the evidence base has evolved significantly since then.

The Guideline Controversy Explained

The shift in medical thinking is important to understand. AAOS softened its position from “strongly against” to “not for routine use” in 2021—a meaningful distinction that allows for use in appropriate patients based on clinical judgment.

Meanwhile, other respected organizations have taken a different view entirely:

OARSI (Osteoarthritis Research Society International) in 2019 acknowledged that HA provides pain relief beyond 12 weeks and has a favorable safety profile compared to repeated steroid injections.

VA/DoD Clinical Practice Guidelines (2020) conditionally recommend HA for patients who meet specific criteria, recognizing its value in the treatment continuum.

American College of Rheumatology (2019) uses “conditional” language, meaning the decision depends on individual patient circumstances—not a blanket prohibition.

The bottom line: No major guideline outright prohibits HA use. The language has shifted from “don’t do this” to “use clinical judgment for appropriate patients.”

Yet many insurers haven’t updated their policies to reflect this evolution.

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The Real Cost Without Coverage

The Financial Burden

For many patients, especially those on fixed incomes or managing multiple health conditions, $1,600+ for a treatment course is prohibitive. This creates an impossible choice: live with untreated pain or deplete savings for a treatment that should be covered.

Some patients delay treatment until they qualify for Medicare at 65, enduring years of unnecessary pain. Others skip the treatment entirely and end up needing knee replacement surgery sooner than they might have otherwise.

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The Coverage Irony

Here’s what doesn’t make sense from either a medical or economic perspective:

Research shows that HA injections can delay knee replacement by 1-3+ years in appropriate patients. That’s years of:

• Preserved natural joint function
• Avoided surgical risk
• Reduced likelihood of revision surgery
• Lower overall healthcare costs

By denying coverage for a $1,500 treatment, some insurers are accelerating the need for a $40,000+ surgery. The math doesn’t favor patients or the healthcare system.

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Your Options If Denied Coverage

Being denied coverage doesn’t mean you’re out of options. Here’s what you can do:

1. Check Your Specific Plan’s Policy

Don’t assume your plan doesn’t cover HA just because your insurer’s name appears on the non-coverage list. Coverage can vary by:

• Specific plan tier (Gold, Silver, Bronze)
• Employer group policies
• State regulations
• Plan year

2. Get Documentation of Failed Treatments

Most coverage criteria require proof that you’ve tried and failed other treatments first. Document:

• Physical therapy: Dates, duration, outcomes
• Over-the-counter medications: What you tried, how long, why they didn’t work
• Prescription medications: Names, dosages, side effects
• Cortisone injections: Dates, temporary relief, limitations

This documentation becomes essential for appeals.

3. Ask Your Doctor for a Letter of Medical Necessity

A well-written letter from your physician can make the difference in an appeal. The letter should include:

• Your specific diagnosis with imaging confirmation
• Failed conservative treatments
• Functional limitations affecting your daily life
• Why HA is appropriate for your case
• References to current guidelines (OARSI, VA/DoD) that support use

4. Reference Current Guidelines That Support HA

When appealing, cite the updated evidence:

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How to Appeal a Coverage Denial

The appeals process can feel intimidating, but many denials are overturned. Here’s the process:

Step 1: Understand the Denial

Read your denial letter carefully. It should explain:

• The specific reason for denial
• The policy language being cited
• Your appeal rights and deadlines

Step 2: Request an Internal Appeal

Deadline: Most plans give you 180 days to file an internal appeal. Don’t wait—file as soon as possible.

Step 3: Request Peer-to-Peer Review

Ask your doctor to request a peer-to-peer review with the insurance company’s medical director. This allows your physician to explain your case directly to another physician at the insurance company.

Step 4: External Review (If Internal Appeal Fails)

If your internal appeal is denied, you have the right to an external review by an independent third party. This review is binding on the insurance company.

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Alternative Payment Options

If appeals don’t work or you need treatment before the process concludes, consider these options:

Payment Plans

Many orthopedic practices offer payment plans for self-pay patients. Ask about:

• Interest-free payment periods
• Monthly payment amounts
• Discount for paying in full

Health Savings Account (HSA) or Flexible Spending Account (FSA)

If you have an HSA or FSA, gel injections are typically an eligible expense. This allows you to pay with pre-tax dollars, effectively reducing your cost by your marginal tax rate.

Manufacturer Patient Assistance Programs

Some HA manufacturers offer patient assistance programs for those without coverage. Contact the manufacturer of your prescribed brand directly.

Medical Credit Cards

Options like CareCredit offer financing specifically for medical expenses. Some offer promotional periods with no interest if paid in full within a specified timeframe.

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Medicare as an Option

If you’re 65 or older (or qualify due to disability), Medicare may be your best path to coverage.

Medicare Advantage Considerations

If you have Medicare Advantage (Part C), coverage may vary by plan. Some MA plans have added restrictions or prior authorization requirements. Check your specific plan before scheduling treatment.

Learn more: Medicare Coverage for Joint Injections: Your Questions Answered

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Questions to Ask Your Insurance Company

Before scheduling treatment, call your insurer and ask these specific questions:

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Advocating for Yourself

Dealing with insurance denials is frustrating, but persistence often pays off. Remember:

You deserve access to treatments that can improve your quality of life. Don’t let an initial denial be the final word.

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Frequently Asked Questions

Why do some insurers cover gel injections while others don’t?

Insurance companies make coverage decisions based on their interpretation of clinical guidelines, cost considerations, and competitive factors. Some have updated their policies to reflect newer evidence, while others continue to rely on outdated 2013 AAOS guidelines.

Will my insurance ever cover gel injections?

Coverage policies can change. Some insurers have begun reconsidering their positions as evidence accumulates. Check annually or when you renew your plan. You can also advocate for coverage changes through your employer’s benefits department.

Is it worth paying out of pocket if my insurance doesn’t cover?

This depends on your financial situation and how much your knee pain affects your quality of life. Consider that HA injections may delay or prevent the need for knee replacement surgery, which has its own costs and risks. Discuss the cost-benefit analysis with your doctor.

Can I switch insurance plans to get coverage?

During open enrollment, you may be able to switch to a plan that covers HA injections. Compare plan formularies carefully before switching, and consider all factors (premiums, deductibles, other coverage) when making your decision.

What if I’m denied coverage through Medicare Advantage?

Medicare Advantage plans must generally provide at least the same coverage as Original Medicare. If your MA plan denies coverage for HA injections that Original Medicare covers, you have grounds for appeal. You may also consider switching to Original Medicare during open enrollment.

How many times can I appeal a denial?

Most insurance plans have multiple levels of internal appeal, followed by external review rights. You typically get at least two internal appeals before external review. Don’t give up after the first denial—many cases are resolved at higher appeal levels.

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The Path Forward

Insurance coverage gaps for gel injections represent a frustrating disconnect between evidence-based medicine and insurance policy. While you can’t single-handedly change insurer behavior, you can:

1. Know your rights to appeal and external review
2. Document your case thoroughly with your doctor
3. Cite current guidelines that support appropriate use
4. Explore alternatives like Medicare (if eligible) or payment plans
5. Advocate through your employer or state insurance commissioner

The 30% coverage gap affects millions of Americans with knee osteoarthritis. By understanding your options and advocating for yourself, you can work toward getting the treatment you need.

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Related Resources

Insurance Cluster

• Does Medicare Cover Gel Injections? 2026 Guide
• Prior Authorization for Gel Injections: What You Need to Know
• Gel Injections vs Knee Replacement: Cost Comparison

Why Coverage Varies

• AAOS vs OARSI: Why Medical Guidelines Disagree on Gel Injections
• Why Your Doctor May Not Have Mentioned Gel Injections

Surgery Delay Evidence

• Can Gel Injections Delay Knee Replacement? 182,000-Patient Study
• 75% of “Bone-on-Bone” Patients Delayed Surgery 7+ Years

Hub Pages

• Hyaluronic Acid Injections: Complete Guide
• What Is Viscosupplementation?
• Medicare Coverage Guide

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This article is for informational purposes only and does not constitute medical, legal, or insurance advice. Coverage policies vary by plan and change over time. Always verify coverage with your specific insurance provider and consult healthcare professionals for medical decisions.

Last updated: January 2025