Aetna Coverage for Knee Braces
Yes, Aetna covers knee braces as durable medical equipment when prescribed.
Quick Facts
| Coverage Aspect | Details |
|---|---|
| Covered? | Yes (as DME) |
| Prescription Required | Yes |
| Prior Authorization | For custom braces |
Types Covered
| Brace Type | Coverage |
|---|---|
| Basic sleeve | Yes |
| Hinged brace | Yes |
| Unloader brace | Yes |
| Custom brace | Yes (may need PA) |
How to Get Coverage
- Get prescription from doctor
- Find in-network DME supplier
- Confirm coverage before ordering
- Pay your cost-share
What Aetna Covers
Aetna classifies knee braces as durable medical equipment (DME), which means they fall under your plan’s DME benefit rather than your standard medical benefit. Most Aetna plans cover off-the-shelf braces like basic sleeves, hinged braces, and unloader braces without prior authorization. You just need a valid prescription from your treating physician that states the medical necessity.
Custom-molded braces are also covered, but Aetna typically requires precertification before you can order one. Your doctor’s office usually handles this by submitting clinical notes that explain why a standard brace will not work for your condition. Common reasons include unusual anatomy, post-surgical support, or severe ligament instability.
Aetna requires that you use an in-network DME supplier to get the best coverage. If you go out of network, you may pay significantly more or the claim could be denied entirely. You can find in-network suppliers through the Aetna provider directory on their website or by calling the member services number on your insurance card.
Typical Costs with Aetna
Your out-of-pocket cost depends on your specific plan and whether you have met your deductible. Here is what most Aetna members can expect:
- PPO in-network: 20% coinsurance after deductible (typically $40-$200 for a standard brace)
- HMO plans: Fixed copay of $20-$75 per brace
- High-deductible plans: Full cost until you meet your deductible, then 20% coinsurance
- Custom braces: Higher cost share, typically $100-$500 after insurance depending on complexity
Keep in mind that Aetna may limit you to one brace per affected joint per year unless your doctor documents a change in condition or damage to the existing brace.
How to Get Approved
- Visit your doctor and describe your knee pain or instability. Your doctor will evaluate whether a brace is medically appropriate.
- Get a written prescription that includes the type of brace recommended and the diagnosis code (ICD-10).
- Check your benefits by calling the number on your Aetna card. Ask about your DME benefit, deductible status, and whether precertification is needed.
- Choose an in-network DME supplier from Aetna’s online directory.
- Submit precertification if you need a custom brace. Your doctor’s office usually handles this step.
- Pick up or receive your brace and pay your copay or coinsurance at the supplier.
If You’re Denied
If Aetna denies your brace claim, you have the right to appeal. Here is what to do:
- Review the denial letter carefully. It will explain the specific reason for denial (missing prescription, out-of-network supplier, etc.).
- File a Level 1 appeal within 180 days of the denial. Include your doctor’s prescription, clinical notes, and a letter of medical necessity.
- Request a peer-to-peer review where your doctor speaks directly with an Aetna medical reviewer. This is often the fastest way to overturn a denial.
- Escalate to an external review if your internal appeal is denied. Aetna is required to offer an independent third-party review at no cost to you.
The most common reason for denial is ordering from an out-of-network supplier, which is easily avoided by checking your network beforehand.
Frequently Asked Questions
Does Aetna cover knee braces for osteoarthritis?
Yes. Aetna covers knee braces for osteoarthritis when your doctor prescribes one and documents medical necessity. Unloader braces, which shift weight away from the damaged part of the knee, are commonly approved for OA patients.
How many knee braces will Aetna pay for per year?
Most Aetna plans cover one brace per affected joint per benefit year. If your brace is damaged or your condition changes significantly, your doctor can request an exception for a replacement.
Do I need a referral to get a knee brace through Aetna?
HMO plans typically require a referral from your primary care doctor. PPO plans usually let you go directly to a specialist or DME supplier with just a prescription. Check your specific plan details to be sure.
Can I buy a brace online and get reimbursed by Aetna?
Generally no. Aetna requires that you use an in-network DME supplier for the claim to be covered. If you buy a brace on your own, you will likely pay the full cost out of pocket.