3 Simple Requirements for Medicare to Cover Your Knee Gel
Medicare covers gel injections since 1997. Meet these 3 simple requirements and your knee treatment may be covered. Here's how to qualify.
By Joint Pain Authority Team
Good News for Medicare Beneficiaries
Medicare has covered viscosupplementation (gel/HA injections) for knee osteoarthritis since 1997. This isn’t experimental or new—it’s an established, medically-validated treatment option.
With just 3 requirements, you may qualify for this non-surgical treatment that provides 6-12 months of relief.
The 3 Requirements
Requirement #1: Confirmed Knee Osteoarthritis Diagnosis
What You Need: An X-ray showing osteoarthritis of the knee
What Qualifies:
- Joint space narrowing
- Bone spurs (osteophytes)
- Bone density changes (sclerosis)
Why It Matters: Medicare needs objective evidence that osteoarthritis is present. An X-ray provides this documentation.
Requirement #2: Failed Conservative Treatment
What You Need: Documentation that you’ve tried other treatments first
What Qualifies:
- Physical therapy
- Over-the-counter pain relievers (NSAIDs)
- Weight management efforts
- Activity modification
- Other conservative measures
Why It Matters: Medicare considers viscosupplementation after simpler treatments haven’t provided adequate relief.
Requirement #3: Active Medicare Part B Coverage
What You Need: Active Medicare Part B enrollment
Part B Covers:
- Outpatient medical services
- Doctor visits
- Injections and procedures
Important: If you have Medicare Advantage, coverage follows Medicare guidelines but your plan may have additional requirements.
What Medicare Covers
The Treatment
| Component | Covered by Part B |
|---|---|
| Office visit | Yes |
| Injection procedure | Yes |
| Hyaluronic acid medication | Yes |
| X-ray imaging | Yes |
| Fluoroscopy guidance | Yes |
What You’ll Pay
With Original Medicare (Part B):
After meeting your annual deductible ($240 in 2024):
- Medicare pays 80% of the approved amount
- You pay 20% coinsurance
- Typical out-of-pocket: $100-$300 per knee
If you have a Medigap supplement:
- Plans F, G, and others may cover your 20%
- Your out-of-pocket may be $0 after deductible
Medicare Advantage Plans
If you have Medicare Advantage (Part C):
Important Differences:
- Must cover what Original Medicare covers
- May require prior authorization
- Must use in-network providers
- Copays vary by plan
- Call the number on your card to verify specifics
Tip: Ask about prior authorization requirements before scheduling.
How to Ensure Coverage
Step 1: Get Proper Documentation
Make sure your medical record includes:
- X-ray results showing knee osteoarthritis
- Notes about conservative treatments you’ve tried
- Documentation of ongoing pain/functional limitations
- Your provider’s statement of medical necessity
Step 2: Choose the Right Provider
Work with a provider who:
- Accepts Medicare assignment
- Has experience with viscosupplementation
- Uses imaging guidance for accuracy
- Will handle prior authorization if needed
Step 3: Verify Before Treatment
Before your procedure:
- Confirm your Part B is active
- Ask about your specific out-of-pocket cost
- Check if prior authorization is required (for MA plans)
- Bring your Medicare card to the appointment
Frequently Asked Questions
How often can I get gel injections with Medicare?
Medicare typically covers one series of injections per knee every 6 months. Most FDA-approved products are given as:
- Single injection (like Synvisc-One, Gel-One)
- Series of 3-5 weekly injections (like Euflexxa, Supartz)
What if my Medicare claim was denied before?
Denials often happen due to:
- Missing documentation of failed conservative treatment
- X-ray not properly documented in the record
- Prior authorization not obtained (for MA plans)
Work with your provider to address the specific reason for denial.
Are all hyaluronic acid brands covered by Medicare?
Most FDA-approved hyaluronic acid products are covered. Common brands include:
- Synvisc-One
- Gel-One
- Euflexxa
- Supartz FX
- Hyalgan
Medicare Coverage Checklist
Before your appointment, verify:
- Part B coverage is active
- Have X-ray showing knee osteoarthritis
- Medical record documents failed conservative treatment
- Provider accepts Medicare assignment
- Understand your out-of-pocket costs
- Prior authorization obtained (if Medicare Advantage)
Ready to Check Your Eligibility?
Take our 3-minute Knee Health Score Quiz to find out if you may be a candidate for Medicare-covered gel therapy.
Take the Quiz
Or use our detailed Medicare Coverage Checklist to verify your specific coverage.
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Need Help?
Medicare Helpline: 1-800-MEDICARE (1-800-633-4227)
Available 24/7 to answer questions about your specific coverage.
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