Medicare Coverage for Knee Injections: Complete 2025 Guide

Understanding Medicare Coverage for Joint Injections

If you’re considering knee injections for osteoarthritis, understanding your Medicare coverage can save you money and prevent unexpected bills. This guide explains what’s covered, what you’ll pay, and how to ensure your claims are approved.

Quick Coverage Summary

Why Medicare Coverage Matters More Than Ever

With some commercial insurers—including BCBS Illinois effective January 2026—discontinuing viscosupplementation coverage, Medicare’s stable, continued coverage is increasingly valuable.

Medicare vs. Commercial Insurance Stability

If You’re Losing Commercial Coverage

If your commercial insurer is ending viscosupplementation coverage:

1. Check Medicare eligibility — Are you 65+ or have a qualifying disability?
2. Review enrollment periods — Initial, General, and Special Enrollment windows vary
3. Compare plan options — Original Medicare vs. Medicare Advantage
4. Find Medicare-accepting providers — Look for specialists with imaging-guided injection expertise

Medicare beneficiaries can take comfort knowing that federal coverage criteria have remained stable for nearly three decades, reflecting the treatment’s established role in osteoarthritis management.

Note: Some commercial insurers are reducing or eliminating viscosupplementation coverage. For example, BCBS Illinois announced coverage discontinuation effective January 2026. Always verify current coverage with your specific plan.

Medicare Part B Coverage for HA Injections

What’s Covered

Medicare Part B covers viscosupplementation (hyaluronic acid injections) for knee osteoarthritis when:

1. You have documented knee osteoarthritis

   • X-ray evidence showing joint changes
   • Clinical diagnosis in your medical records

2. Conservative treatments have been tried

   • Physical therapy
   • Over-the-counter pain medications
   • Activity modifications
   • Documentation showing these weren’t sufficient

3. Medical necessity is established

   • Your provider documents why injections are appropriate
   • Treatment plan is in your medical records

4. Provider is Medicare-enrolled

   • Treatment must be from a provider who accepts Medicare
   • Provider must bill Medicare directly

What You’ll Pay

With Original Medicare (Part A and B):

• Annual deductible: $240 (2025)
• Coinsurance: 20% of the Medicare-approved amount
• Typical out-of-pocket: $60-$150 per injection series

Example: If Medicare approves $500 for an HA injection series:

• Medicare pays: $400 (80%)
• You pay: $100 (20%) after your deductible

Medicare Advantage Plans

If you have Medicare Advantage (Part C):

• Coverage rules follow Original Medicare guidelines
• Copays may vary by plan
• Prior authorization may be required
• Network restrictions may apply
• Always verify coverage with your specific plan before treatment

Cortisone Injections Under Medicare

Cortisone (corticosteroid) injections are also covered under Medicare Part B with fewer restrictions than HA injections.

Coverage Requirements

• Medical necessity documentation
• Treatment by Medicare-enrolled provider
• No specific “failed conservative treatment” requirement

Limitations

While coverage is easier to obtain, cortisone has important limitations:

• Typically limited to 3-4 injections per joint per year
• Research suggests potential cartilage damage with repeated use
• Shorter duration of relief (weeks vs. months with HA)

What Medicare Does NOT Cover

PRP (Platelet-Rich Plasma)

Medicare considers PRP experimental and does not cover it for any joint condition. You will pay 100% out-of-pocket.

Stem Cell Injections

Medicare does not cover stem cell injections for osteoarthritis. These treatments:

• Lack sufficient evidence for Medicare approval
• Cost $3,000-$10,000+ per treatment
• Are often aggressively marketed despite limited proof

Regenerative Medicine Treatments

Most “regenerative” treatments marketed for joint pain are not covered by Medicare. Be cautious of clinics that:

• Claim to “regenerate” cartilage
• Promise outcomes not supported by research
• Don’t clearly disclose costs upfront

How to Ensure Your Claims Are Approved

Before Treatment

1. Verify provider enrollment

   • Ask: “Are you enrolled in Medicare?”
   • Ask: “Do you accept Medicare assignment?”

2. Confirm coverage

   • Contact Medicare: 1-800-MEDICARE (1-800-633-4227)
   • Or check MyMedicare.gov

3. Document conservative treatment

   • Keep records of physical therapy
   • Document medication use
   • Note activity modifications tried

4. Get imaging

   • X-rays are typically required
   • Ensure they’re in your medical records

During Treatment

5. Verify billing codes
   • Your provider should use correct CPT and diagnosis codes
   • Ask for an itemized statement

If You’re Denied

6. Appeal promptly
   • You have 120 days to file an appeal
   • Request a written explanation of the denial
   • Work with your provider on the appeal

Common Reasons for Claim Denials

Documentation Issues

• Missing conservative treatment records: Keep documentation of PT, medications tried
• No X-ray evidence: Imaging showing OA should be on file
• Incomplete medical necessity: Provider notes should clearly state why injections are needed

Provider Issues

• Provider not enrolled: Always verify Medicare enrollment
• Incorrect billing: Wrong codes can cause automatic denials
• Missing prior authorization: Some Medicare Advantage plans require this

Timing Issues

• Too soon after previous series: Most plans require 6 months between HA injection series
• Exceeding frequency limits: Cortisone may be limited to a few injections per year

Medicare vs. Medicare Advantage for Injections

Which Is Better?

It depends on your situation:

• Original Medicare: More flexibility in choosing providers, predictable costs
• Medicare Advantage: May have lower copays but more restrictions

Questions to Ask Before Treatment

Ask your provider:

1. “Are you enrolled in Medicare and do you accept assignment?”
2. “What will my out-of-pocket cost be?”
3. “Do you have documentation of my conservative treatment history?”
4. “Will you handle the Medicare billing?”

Ask Medicare or your plan:

1. “Is viscosupplementation covered under my plan?”
2. “Do I need prior authorization?”
3. “What is my deductible status?”
4. “Are there network restrictions?”

Red Flags to Watch For

Be cautious of providers who:

• Don’t clearly explain costs before treatment
• Ask you to pay upfront and “file with Medicare yourself”
• Aren’t enrolled in Medicare but claim to treat Medicare patients
• Offer “free” services (may violate anti-kickback laws)
• Transport you for “free” (may be improper inducement)

Medicare Fraud Warning Signs

• Billing for services not provided
• Upcoding (billing for more expensive services)
• Unnecessary treatments recommended
• Pressure to receive more treatments than medically necessary

Report suspected fraud: 1-800-HHS-TIPS

Supplemental Insurance (Medigap)

If you have a Medigap policy, it may cover:

• Part B deductible (Plans C, F for those eligible before 2020)
• 20% coinsurance

Check your specific Medigap plan for details.

Key Takeaways

1. HA injections ARE covered by Medicare Part B for knee OA
2. Documentation is critical — keep records of conservative treatments tried
3. Verify provider enrollment before treatment
4. PRP and stem cells are NOT covered — you’ll pay 100%
5. Appeals are possible if you’re denied
6. Be wary of scams — Medicare fraud is common in joint pain treatment

Related Resources

• BCBS Illinois Coverage Changes - Important update for BCBS members
• Hyaluronic Acid Injections Guide
• HA vs. Cortisone: Understanding Your Options
• How to Choose a Joint Pain Clinic
• Red Flags in Joint Pain Treatment