Medicare Coverage Guide for Knee Relief

Your Complete Medicare Coverage Guide

Understanding Medicare coverage for joint pain treatment doesn’t have to be complicated. This guide explains exactly what’s covered, what you’ll pay, and how to ensure your treatment is approved.

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Part 1: Medicare Basics for Joint Pain

Medicare Part B: Your Foundation

Medicare Part B covers outpatient medical services, including:

• Doctor visits
• Outpatient procedures
• Injectable medications
• Physical therapy
• Durable medical equipment

2024 Part B Costs:

• Monthly premium: $174.70 (standard)
• Annual deductible: $240
• Coinsurance: 20% of approved amount

How Coverage Works

1. You pay your Part B premium monthly
2. You pay the first $240 of covered services (deductible)
3. After deductible, Medicare pays 80%
4. You pay 20% (coinsurance)

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Part 2: Treatments Covered by Medicare

Viscosupplementation (Gel Injections)

Coverage Status: COVERED since 1997

Requirements:

• Diagnosis of knee osteoarthritis
• Documentation of failed conservative treatment
• Medical necessity established

What’s Included:

• Hyaluronic acid medication
• Injection procedure
• Office visit
• Imaging guidance (fluoroscopy or ultrasound)

Covered Brands:

• Synvisc-One
• Gel-One
• Euflexxa
• Supartz FX
• Hyalgan
• And others FDA-approved for knee OA

Frequency:

• One series per knee per 6 months

Cortisone Injections

Coverage Status: COVERED

What’s Included:

• Corticosteroid medication
• Injection procedure
• Imaging guidance when used

Frequency:

• Generally 3-4 per joint per year

Physical Therapy

Coverage Status: COVERED

2024 Therapy Cap:

• Combined PT/Speech therapy: $2,330/year
• Exceptions available for medical necessity

What’s Included:

• Evaluation and assessment
• Therapeutic exercises
• Manual therapy
• Patient education

Knee Braces (DME)

Coverage Status: COVERED

Requirements:

• Prescription from doctor
• Medical necessity established
• Obtained from Medicare-approved supplier

Types Covered:

• Functional braces
• Unloader braces
• Post-operative braces

X-Rays and Imaging

Coverage Status: COVERED

Includes:

• Diagnostic X-rays
• MRI when medically necessary
• Fluoroscopy for guided procedures

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Part 3: What Medicare Doesn’t Cover

Not Covered for Joint Pain

Treatment	Coverage Status
PRP (Platelet-Rich Plasma)	NOT COVERED
Stem cell injections	NOT COVERED
Prolotherapy	NOT COVERED
HA for non-knee joints	USUALLY NOT COVERED
Experimental treatments	NOT COVERED

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Part 4: What You’ll Pay

With Original Medicare Only

After meeting your $240 deductible:

Treatment	Medicare Pays	You Pay
Gel injection	80%	20% (~$100-300)
Cortisone	80%	20% (~$20-50)
PT session	80%	20% (~$20-40)
Knee brace	80%	20% (varies)

With Medigap Supplement

If you have Medigap Plan F, G, or similar:

Treatment	Medicare Pays	Medigap Pays	You Pay
Gel injection	80%	20%	$0 after deductible
Cortisone	80%	20%	$0 after deductible
PT session	80%	20%	$0 after deductible

With Medicare Advantage (Part C)

• Copays vary by plan
• May require prior authorization
• Must use in-network providers
• Check your specific plan details

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Part 5: Medicare Advantage Considerations

Key Differences from Original Medicare

Factor	Original Medicare	Medicare Advantage
Prior authorization	Rarely needed	Often required
Network	Any Medicare provider	In-network only
Referrals	Not required	May be required
Out-of-pocket max	None	Yes (provides protection)

Before Treatment with MA

1. Call the number on your card
2. Ask about prior authorization requirements
3. Verify provider is in-network
4. Get cost estimate in writing

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Part 6: Ensuring Coverage

Step-by-Step Guide

Step 1: Verify Your Coverage

• Confirm Part B is active
• Check if deductible has been met
• Know your supplement/advantage plan details

Step 2: Meet Requirements

• Get X-ray documentation
• Try conservative treatments first
• Ensure diagnosis is properly coded

Step 3: Choose the Right Provider

• Accepts Medicare assignment
• In-network (if Medicare Advantage)
• Experienced with your treatment

Step 4: Prepare for Appointment

• Bring Medicare card
• Bring supplement/MA card
• Bring list of treatments tried
• Ask for cost estimate

Required Documentation

Your medical record should include:

• X-ray showing osteoarthritis
• Notes on conservative treatments tried
• Functional limitations documented
• ICD-10 diagnosis code for knee OA
• Statement of medical necessity

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Part 7: Common Issues and Solutions

Issue: Prior Authorization Denied

Solution:

• Ask for reason in writing
• Ensure all documentation submitted
• Request peer-to-peer review
• File appeal if appropriate

Issue: Wrong Diagnosis Code

Solution:

• Verify ICD-10 code is correct
• M17.11 (primary OA, right knee)
• M17.12 (primary OA, left knee)
• Ask provider to correct if wrong

Issue: Provider Doesn’t Accept Assignment

Solution:

• You may pay more out-of-pocket
• Find a provider who accepts assignment
• Ask if they’ll accept assignment for you

Issue: Out-of-Network (MA Plans)

Solution:

• Use in-network provider
• Request authorization for out-of-network
• Understand extra costs before proceeding

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Part 8: Appeals and Denials

If Treatment Is Denied

1. Get it in writing - Request explanation
2. Review the reason - Often documentation issue
3. Gather evidence - Medical records, notes
4. File appeal - Within 120 days

Appeal Levels

1. Redetermination by MAC
2. Reconsideration by QIC
3. ALJ hearing
4. Medicare Appeals Council
5. Federal court

Most successful appeals are resolved at Level 1-2.

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Part 9: Cost Comparison

Treatment Cost Examples

Treatment	Total Cost	Medicare Pays	Your Cost (with supplement)
Gel injection series	$1,500	$1,200	$60 (after deductible)
Single cortisone	$250	$200	$0-10
12 PT sessions	$1,800	$1,440	$0-72
Unloader brace	$800	$640	$0-32

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Part 10: Key Phone Numbers

Medicare Helpline: 1-800-MEDICARE (1-800-633-4227)

• Available 24/7
• Can verify coverage
• Help with claims issues

State Health Insurance Assistance Program (SHIP):

• Free Medicare counseling
• Help understanding benefits
• Assistance with appeals

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Medicare Coverage Checklist

Before your appointment:

• Part B coverage verified active
• Deductible status known
• Supplement/MA details confirmed
• Provider accepts Medicare assignment
• Prior authorization obtained (if MA)
• X-ray documentation in record
• Conservative treatment documented
• Cost estimate received

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Next Steps

Use our Medicare Coverage Checklist to work through verification step-by-step.

Or take our Knee Health Score Quiz to assess your candidacy for Medicare-covered treatment.