Navigating Medicare Coverage for Joint Pain Treatment

Key Takeaways

• Medicare Part B covers most joint pain treatments including doctor visits, injections, and physical therapy
• Prior authorization requirements vary by treatment and may require trying conservative options first
• Medicare Advantage plans have different coverage rules than Original Medicare
• Understanding coverage before treatment prevents surprise bills
• Appeal rights exist if coverage is denied

Medicare covers most medically necessary joint pain treatments, but understanding the system can feel overwhelming. With different parts, plans, and coverage rules, many seniors struggle to know what’s covered, what requires prior authorization, and what will cost them out-of-pocket.

This guide breaks down Medicare coverage for joint pain treatments in plain language, helping you access the care you need without financial surprises.

Understanding Medicare Parts: A Quick Overview

Medicare has multiple parts that cover different aspects of healthcare. For joint pain treatment, you’ll primarily interact with Part B and possibly Part D.

Medicare Part A (Hospital Insurance)

What it covers:

• Inpatient hospital stays
• Skilled nursing facility care after hospitalization
• Hospice care
• Some home healthcare

For joint pain patients: Part A covers joint replacement surgery when you’re admitted to the hospital, plus up to 100 days in a skilled nursing facility if you need rehabilitation after surgery.

Costs:

• Most people pay no premium (if they or their spouse paid Medicare taxes)
• Deductible: $1,632 per benefit period (2024)
• Days 1-60: $0 copay after deductible
• Days 61-90: $408 copay per day
• Days 91+: $816 copay per “lifetime reserve day”

Medicare Part B (Medical Insurance)

What it covers:

• Doctor visits and outpatient care
• Diagnostic tests and imaging
• Physical therapy
• Joint injections
• Durable medical equipment (braces, canes, walkers)
• Outpatient surgery (including same-day joint replacement)

For joint pain patients: Part B is your primary coverage for arthritis treatment. This includes office visits, X-rays, injections, physical therapy, and most non-surgical treatments.

Costs:

• Standard premium: $174.70/month (2024, varies by income)
• Annual deductible: $240 (2024)
• After deductible: You pay 20% of Medicare-approved amount
• No out-of-pocket maximum (consider supplemental insurance)

Medicare Part D (Prescription Drug Coverage)

What it covers:

• Prescription medications

For joint pain patients: Covers oral medications like NSAIDs, pain relievers, and other prescribed medications for arthritis management.

Costs:

• Varies by plan
• Monthly premium + deductible + copays or coinsurance

Medicare Advantage (Part C)

An alternative to Original Medicare offered by private insurance companies. Includes Part A, Part B, and usually Part D coverage.

Key differences affecting joint pain patients:

• Often includes additional benefits (vision, dental, hearing)
• Uses provider networks (must see in-network doctors)
• Requires referrals for specialists in most plans
• May have different coverage rules than Original Medicare
• Often has out-of-pocket maximums (helpful protection)
• Prior authorization requirements may be stricter

Important: Some Medicare Advantage plans are changing coverage for certain treatments. Blue Cross Blue Shield Illinois recently announced elimination of viscosupplementation (gel injection) coverage starting 2026. Always verify your specific plan’s coverage.

What Medicare Covers for Joint Pain Treatment

Doctor Visits and Consultations

Original Medicare Coverage:

• Primary care visits: Covered under Part B
• Specialist visits (orthopedists, rheumatologists, pain management): Covered under Part B
• You pay: 20% of Medicare-approved amount after meeting deductible

What you need:

• Referrals: Not required for Original Medicare
• Prior authorization: Not required for office visits

Diagnostic Imaging and Tests

X-rays: Fully covered when medically necessary

• Used to diagnose arthritis severity
• No prior authorization needed
• You pay: 20% after deductible

MRI Scans: Covered when medically necessary

• May require prior authorization
• Must meet medical necessity criteria
• You pay: 20% after deductible

CT Scans: Covered when medically necessary

• Similar requirements to MRI
• Prior authorization often required

Bone Density Tests: Covered once every 24 months

• Important if considering medications affecting bone health

Blood Tests: Covered when medically necessary

• Used to rule out inflammatory arthritis
• No prior authorization for basic tests

Physical Therapy

Coverage:

• Medically necessary physical therapy is covered
• Must be prescribed by a doctor
• Requires periodic re-evaluation and certification

Limitations:

• Medicare reviews therapy after a certain dollar threshold ($2,290 in 2024)
• Must show continued medical necessity and progress
• Some conditions qualify for exceptions to therapy caps

You pay:

• 20% of Medicare-approved amount after deductible
• Typically $20-40 per session depending on your location

Joint Injections

Medicare covers several types of joint injections under Part B.

Corticosteroid (Cortisone) Injections

Coverage: Yes, fully covered when medically necessary

• No frequency limits from Medicare (though doctors recommend 3-4 per year)
• Can be repeated as needed
• No prior authorization required

You pay: 20% after deductible (typically $30-60 depending on location)

Hyaluronic Acid Injections (Viscosupplementation)

Coverage: Yes, covered for knee osteoarthritis under Part B

• FDA-approved brands covered (Synvisc, Euflexxa, Monovisc, Durolane, Orthovisc, Supartz, Hyalgan, Gel-One)
• Can be repeated every 6 months if effective
• Both single-injection and multi-injection series covered

Requirements:

• Diagnosis of knee osteoarthritis
• Failed conservative treatment (usually 3 months of non-surgical management)
• No prior authorization required for Original Medicare
• Medicare Advantage plans may require prior authorization

Important changes:

• Some Medicare Advantage plans eliminating coverage (BCBS Illinois 2026)
• Always verify your specific plan’s coverage
• Off-label use for other joints (hip, shoulder) not covered

You pay: 20% after deductible (typically $100-300 depending on brand and whether single or multiple injections)

Read more: Medicare Coverage for Joint Injections FAQ

PRP (Platelet-Rich Plasma) Injections

Coverage: No

• Considered experimental/investigational by Medicare
• Not FDA-approved for arthritis treatment
• You pay full cost out-of-pocket ($500-$2,000 per injection)

Stem Cell Injections

Coverage: No

• Not FDA-approved for arthritis
• Considered experimental
• You pay full cost out-of-pocket ($3,000-$10,000+)

Medications

Oral Medications (Prescription)

Coverage: Part D plans cover prescription medications

• NSAIDs (when prescribed)
• Pain medications
• Disease-modifying drugs for inflammatory arthritis

Costs vary by:

• Your specific Part D plan
• Drug tier
• Pharmacy (mail-order often cheaper)

Injectable Medications (Intra-articular)

Coverage: Part B covers medications injected into joints (not Part D)

• This includes hyaluronic acid and corticosteroids
• “Buy and bill” model—doctor purchases medication and bills Medicare

Over-the-Counter Medications

Coverage: Not covered by Medicare

• Includes OTC NSAIDs, acetaminophen, topical creams
• You pay full cost
• May be covered by supplemental plans

Durable Medical Equipment (DME)

What’s covered:

• Canes: Covered when medically necessary
• Walkers: Covered with doctor’s order
• Wheelchairs: Covered based on medical necessity
• Knee braces: Covered when medically necessary (must be custom-fitted or certain types)
• Compression sleeves: Usually not covered (considered over-the-counter)

Requirements:

• Prescription from your doctor
• Supplier must be Medicare-enrolled
• Must be medically necessary

You pay: 20% of Medicare-approved amount after deductible

Surgical Procedures

Joint Replacement Surgery

Coverage: Yes, fully covered when medically necessary

Part A covers:

• Hospital stay
• Operating room
• Anesthesia
• Skilled nursing facility (up to 100 days if needed)

Part B covers:

• Surgeon’s fees
• Anesthesiologist’s fees
• Outpatient surgery facility fees (if done as outpatient)

Requirements:

• Medical necessity (conservative treatments failed)
• No prior authorization for Original Medicare
• Medicare Advantage may require prior authorization

You pay:

• Part A deductible if admitted
• 20% of Part B services (surgeon, anesthesiologist)
• Can be significant; supplemental insurance recommended

Arthroscopy (Scope Surgery)

Coverage: Yes, when medically necessary

• Less commonly recommended for arthritis alone
• More often for mechanical issues (loose cartilage, meniscus tears)

Requirements:

• Medical necessity documentation
• Prior conservative treatment

Newer Surgical Options

• Cartilage restoration procedures: Coverage varies; may require prior authorization
• Robotic-assisted surgery: Covered at same rate as traditional surgery (no extra cost)

Prior Authorization: What You Need to Know

Prior authorization (PA) is when your doctor must get approval from Medicare (or your Medicare Advantage plan) before providing certain services or treatments.

Original Medicare (Parts A & B)

Good news: Original Medicare has very few prior authorization requirements for joint pain treatment.

Services that typically DON’T require PA:

• Doctor visits
• X-rays
• Most injections (including hyaluronic acid for knees)
• Physical therapy (though may be reviewed after certain spending thresholds)
• Joint replacement surgery

Services that MAY require PA:

• Advanced imaging (MRI, CT scans) in some states
• Certain durable medical equipment
• Some expensive medications under Part B

Medicare Advantage Plans

Important difference: Private Medicare Advantage plans can require prior authorization for many more services.

Commonly requires PA in Advantage plans:

• MRI and CT scans
• Joint injections (especially hyaluronic acid)
• Physical therapy beyond certain number of visits
• Joint replacement surgery
• Specialty referrals
• Durable medical equipment

How Prior Authorization Works

1. Doctor initiates: Your doctor submits a PA request with medical documentation
2. Plan reviews: Insurance reviews medical necessity
3. Decision timeline: Usually 14 days for standard, 72 hours for urgent
4. Approval or denial: You’re notified of the decision
5. If denied: You have appeal rights

Tips for Successful Prior Authorization

Document conservative treatment: Keep records showing you’ve tried:

• Physical therapy (dates, number of sessions)
• Medications (what you’ve tried, side effects, lack of effectiveness)
• Lifestyle modifications (weight loss efforts, activity changes)
• Duration of symptoms

Your doctor should include:

• Diagnosis codes
• Severity of symptoms
• Failed treatments and why
• Functional limitations
• Medical necessity justification

If your PA is denied:

• Ask why specifically
• Request peer-to-peer review (doctor to doctor)
• File an appeal (see section below)

Understanding Your Out-of-Pocket Costs

Medicare’s 20% coinsurance can add up quickly. Here’s what to expect for common joint pain treatments.

Typical Costs (Your 20% Portion)

Office visits:

• Primary care: $20-40
• Specialist: $25-60

Diagnostic imaging:

• X-ray: $20-40
• MRI: $80-200
• CT scan: $60-150

Physical therapy:

• Per session: $20-40
• Course of treatment (12 sessions): $240-480

Injections:

• Cortisone: $30-60
• Hyaluronic acid (single injection): $100-200
• Hyaluronic acid (series of 3-5): $150-300

Joint replacement surgery:

• Hospital portion (Part A): $1,632 deductible
• Surgeon, anesthesiologist (Part B): $1,000-3,000 (20% of total)
• Total out-of-pocket: $3,000-5,000+ without supplemental insurance

Protecting Yourself: Supplemental Coverage

Medigap (Medicare Supplement Insurance)

Private insurance that helps pay your share of costs:

• Covers Part B 20% coinsurance
• Covers Part A deductible and coinsurance
• Plans G and N most popular
• Premium: $100-300/month depending on location and age

Medicare Advantage Out-of-Pocket Maximum

Most Advantage plans have annual maximums:

• Typical range: $3,000-7,000 per year
• Once reached, plan pays 100%
• Provides financial protection for major expenses

Lower Your Costs

Use preferred providers:

• Original Medicare: Any Medicare-accepting provider
• Advantage: Stay in-network to minimize costs

Generic medications when available:

• Part D costs lower for generics
• Ask doctor about generic alternatives

Medicare Savings Programs: If you have limited income, you may qualify for help:

• QMB (Qualified Medicare Beneficiary): Pays Part B premium and cost-sharing
• SLMB (Specified Low-Income Medicare Beneficiary): Pays Part B premium
• Income limits: Varies by state, typically 100-135% of federal poverty level

Extra Help (Low-Income Subsidy):

• Helps with Part D prescription drug costs
• Can save $5,000+ per year

Contact your State Health Insurance Assistance Program (SHIP) for eligibility help.

Medicare Advantage vs. Original Medicare for Joint Pain

Choosing between Original Medicare and Medicare Advantage significantly impacts your joint pain treatment access and costs.

Original Medicare Benefits

Advantages:

• Freedom to see any Medicare-accepting doctor nationwide
• No referrals needed for specialists
• Fewer prior authorization requirements
• Consistent coverage rules nationally
• Can add Medigap to limit out-of-pocket costs

Disadvantages:

• No out-of-pocket maximum (without Medigap)
• 20% coinsurance can be significant
• Doesn’t include prescription drug coverage (need separate Part D)
• Separate premiums for Part B, Part D, and Medigap

Medicare Advantage Benefits

Advantages:

• Out-of-pocket maximum provides financial protection
• Often includes Part D drug coverage
• May include extra benefits (vision, dental, gym membership)
• One plan, one card simplicity
• Often lower monthly premiums than Original Medicare + Medigap + Part D

Disadvantages:

• Must use network providers (except emergencies)
• Usually requires referrals to see specialists
• More prior authorization requirements
• Coverage varies by plan and can change annually
• Travel outside service area may limit coverage

Which Is Better for Joint Pain Patients?

Consider Original Medicare + Medigap if:

• You want maximum flexibility in choosing doctors
• You travel frequently or spend winters in another state
• You’re managing multiple chronic conditions requiring specialists
• You want predictable, low out-of-pocket costs
• You can afford the higher monthly premiums

Consider Medicare Advantage if:

• You prefer lower monthly premiums
• You’re comfortable with network restrictions
• You stay in one geographic area
• You want an out-of-pocket maximum for protection
• You value extra benefits like dental and vision

For expensive treatments like joint replacement:

• Original Medicare + Medigap may provide better protection
• Advantage plans’ out-of-pocket maximum also protects you
• Compare specific costs for your situation

When Coverage Is Denied: Your Appeal Rights

If Medicare denies coverage for a joint pain treatment you believe should be covered, you have strong appeal rights.

Why Denials Happen

Common reasons:

• Treatment deemed not medically necessary
• Prior authorization wasn’t obtained (Advantage plans)
• Documentation incomplete
• Treatment considered experimental
• Provider not in network (Advantage plans)
• Frequency limits exceeded

The Five-Level Appeal Process

Level 1: Redetermination (Original Medicare) or Internal Appeal (Advantage)

• Deadline: 120 days from denial
• Who reviews: Medicare contractor or Advantage plan
• Timeline: 60 days (standard), 72 hours (expedited if health at risk)
• What to include:
  • Letter explaining why you disagree
  • Supporting medical records
  • Doctor’s letter of medical necessity
  • Research supporting treatment

Level 2: Reconsideration (Original Medicare) or External Appeal (Advantage)

• When: If Level 1 appeal denied
• Deadline: 180 days from Level 1 decision
• Who reviews: Independent reviewer
• Timeline: 60 days (standard), 72 hours (expedited)

Level 3: Administrative Law Judge Hearing

• When: If Level 2 denied and dispute is $180+ (2024)
• Timeline: 90 days
• Format: Phone or video hearing

Levels 4 & 5:

• Medicare Appeals Council review
• Federal court (for disputes $1,850+)

Expedited Appeals

If waiting could seriously jeopardize your health, request an expedited appeal:

• Your doctor must support urgency
• Decision within 72 hours
• Available at Levels 1 and 2

Tips for Successful Appeals

Get your doctor involved:

• Strong doctor support is critical
• Letter should detail medical necessity
• Include why alternative treatments inadequate

Document everything:

• Prior treatments tried and failed
• How condition affects daily function
• Why this specific treatment is needed now

Use research and guidelines:

• Medical journal articles supporting treatment
• Professional society recommendations
• FDA approval information

Be persistent:

• Many denials are overturned on appeal
• Don’t give up after first denial
• Consider getting help from patient advocacy organizations

Planning Ahead: Maximizing Your Coverage

Before Starting Treatment

Verify coverage:

• Call Medicare or your Advantage plan
• Get confirmation in writing if possible
• Verify provider is in-network (Advantage)
• Ask about prior authorization requirements

Understand your costs:

• Ask about Medicare-approved amounts
• Calculate your 20% responsibility
• Check if you’ve met annual deductible
• Verify pharmacy coverage for medications

Check provider credentials:

• Ensure provider accepts Medicare assignment
• Verify they’re enrolled in Medicare
• For Advantage, confirm they’re in-network

Timing Considerations

End of year:

• If you’ve met out-of-pocket maximum (Advantage), consider scheduling treatments before year-end
• If close to deductible, might make sense to complete treatment in same year

Medicare Annual Election Period (October 15 - December 7):

• Review your plan’s coverage for next year
• Some plans change coverage (like BCBS Illinois eliminating viscosupplementation)
• Switch plans if current plan eliminating needed coverage
• Changes take effect January 1

Keeping Good Records

Maintain files with:

• Explanation of Benefits (EOB) statements
• Medical records
• Prior authorization approvals
• Prescription records
• Communication with Medicare/insurance

Why this matters:

• Needed for appeals
• Verify billing accuracy
• Track spending toward deductible/out-of-pocket max
• Tax deduction documentation (if itemizing)

Frequently Asked Questions

Does Medicare cover gel shots for knees?

Yes, Original Medicare Part B covers hyaluronic acid (gel) injections for knee osteoarthritis. Medicare Advantage plans also generally cover them, but some plans are eliminating coverage (like BCBS Illinois starting 2026). Always verify with your specific plan.

How often will Medicare pay for knee injections?

Medicare doesn’t limit how often you can receive covered injections. However, doctors typically recommend cortisone injections no more than 3-4 times per year in the same joint. Hyaluronic acid injections are usually given every 6 months if effective.

Does Medicare require prior authorization for joint injections?

Original Medicare (Part B) does not require prior authorization for most joint injections, including cortisone and hyaluronic acid for knees. Medicare Advantage plans may require prior authorization—check with your specific plan.

Will Medicare cover injections for shoulders or hips?

Medicare covers cortisone injections for any joint. Hyaluronic acid injections are FDA-approved only for knees, so Medicare coverage for other joints (shoulders, hips) is inconsistent and generally not covered. PRP and stem cell injections are not covered for any joint.

Does Medicare cover physical therapy for arthritis?

Yes, Medicare Part B covers medically necessary physical therapy prescribed by a doctor. You pay 20% after meeting your deductible. Medicare reviews therapy after certain spending thresholds to ensure continued medical necessity.

What if I can’t afford my 20% coinsurance?

Options include:

• Medigap (Medicare Supplement Insurance) to cover the 20%
• Medicare Advantage with lower cost-sharing
• Medicare Savings Programs if you have limited income
• Payment plans with providers
• Discuss lower-cost treatment alternatives with your doctor

Can I see any doctor with Original Medicare?

You can see any doctor who accepts Medicare assignment. About 99% of doctors accept Medicare patients, though some don’t accept assignment (may bill you more). Medicare Advantage plans require you to use network providers except in emergencies.

How do I find out if a treatment requires prior authorization?

For Original Medicare: Call 1-800-MEDICARE. For Medicare Advantage: Call the customer service number on your insurance card. Your doctor’s office can also check for you. Always verify before receiving treatment to avoid surprise denials.

Resources and Help

Medicare Resources

1-800-MEDICARE (1-800-633-4227)

• TTY: 1-877-486-2048
• 24/7 help with coverage questions

Medicare.gov

• Official Medicare website
• Plan comparison tools
• Coverage information

State Health Insurance Assistance Program (SHIP)

• Free, unbiased Medicare counseling
• Help with claims and appeals
• Find your local SHIP at shiphelp.org

Additional Resources

Social Security Administration

• Enrollment in Medicare Parts A and B
• Premium payment issues
• 1-800-772-1213

Medicare Rights Center

• Medicare advocacy and education
• 1-800-333-4114
• medicarerights.org

Centers for Medicare & Medicaid Services (CMS)

• Policy information
• Provider enrollment
• cms.gov

The Bottom Line

Medicare provides comprehensive coverage for most joint pain treatments, from doctor visits and imaging to injections and surgery. Understanding your specific coverage—whether Original Medicare or a Medicare Advantage plan—helps you access the care you need without surprise bills.

Key points to remember:

• Medicare Part B covers most joint pain treatments
• Original Medicare has fewer restrictions than Advantage plans
• Prior authorization requirements vary significantly by plan type
• You have strong appeal rights if coverage is denied
• Supplemental insurance protects against high out-of-pocket costs
• Verify coverage before starting treatment

Don’t let confusion about coverage prevent you from seeking treatment for joint pain. Use the resources in this guide, ask questions, and advocate for yourself. You’ve earned these Medicare benefits—make sure you understand and use them.

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Related Resources:

• Medicare Coverage for Joint Injections FAQ
• BCBS Illinois Ends Viscosupplementation Coverage 2026
• Advocacy Guide: HA Injection Coverage
• Understanding Joint Injections: A Patient’s Complete Guide

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This guide is for educational purposes and provides general information about Medicare coverage. Coverage can change, and specific plans may have different rules. Always verify coverage with Medicare or your specific plan before receiving treatment.

Last updated: January 2025