Does Medicare Cover Injections for Arthritis?

Medicare, a federal health insurance program for those 65 or older and certain younger people with disabilities, helps manage healthcare expenses for chronic conditions like arthritis. Arthritis injections are common for pain and inflammation. Understanding Medicare’s coverage for these injections involves navigating its different parts and provisions, including financial aspects and procedural steps.

Medicare Parts and Coverage for Injections

Medicare coverage for arthritis injections depends on the injection type and administration location. Original Medicare (Parts A and B) and Medicare Advantage Plans (Part C) cover these services. Most outpatient arthritis injections, like corticosteroid and hyaluronic acid injections, are covered by Medicare Part B (Medical Insurance). Part B covers medically necessary injections given by a healthcare professional in a doctor’s office or outpatient clinic.

Corticosteroid injections (cortisone shots) are covered by Medicare Part B when medically necessary for arthritis. Hyaluronic acid injections (viscosupplementation or knee gel injections) are also covered by Original Medicare for knee osteoarthritis. Medical necessity for these injections often requires a diagnosis of symptomatic osteoarthritis confirmed by imaging, and documented failed conservative treatments like pain medication or physical therapy.

Self-administered injectable arthritis medications, such as certain biologics for rheumatoid arthritis, are covered by Medicare Part D (Prescription Drug Coverage). Part D plans are offered by private companies, and coverage depends on the plan’s formulary. If a biologic drug is administered in a doctor’s office, Medicare Part B covers expenses. However, if self-administered, Part D covers the costs.

Medicare Advantage Plans (Part C) are private plans that must provide at least the same coverage as Original Medicare (Parts A and B). They also cover medically necessary arthritis injections, but may have different rules, costs, and networks. Medicare Part A (Hospital Insurance) covers inpatient hospital stays and is not typically relevant for routine outpatient arthritis injections unless administered during an inpatient admission.

Cost Sharing and Financial Considerations

Beneficiaries receiving arthritis injections under Medicare incur out-of-pocket costs based on their coverage. For Part B-covered injections, beneficiaries pay an annual deductible and coinsurance. In 2025, the Part B deductible is $257. After meeting this, Medicare Part B covers 80% of the approved amount, with the beneficiary responsible for the remaining 20% coinsurance. This 20% applies to the injection and associated services like the doctor’s visit.

For self-administered Part D-covered injections, out-of-pocket costs vary by plan and formulary. These costs include monthly premiums, annual deductibles, copayments, and coinsurance. The maximum Part D deductible in 2025 is $590, though some plans have lower or no deductible. After meeting the deductible, beneficiaries typically pay a copayment or coinsurance, often tiered with lower costs for generic drugs.

A significant change for Medicare Part D in 2025 is a $2,000 out-of-pocket cap for prescription drug costs. This cap includes deductibles, copayments, and coinsurance. Once reached, the Part D plan covers 100% of covered medications for the rest of the year, eliminating prior cost-sharing in the catastrophic coverage phase.

Medicare Advantage Plans (Part C) have their own cost-sharing structures, including unique copayments, coinsurance, and deductibles for arthritis injections. These plans may differ from Original Medicare, so beneficiaries should consult their plan documents. Medicare Supplement Insurance (Medigap plans) can help cover some Original Medicare out-of-pocket costs, such as Part B coinsurance and deductibles, reducing a beneficiary’s financial liability.

Steps to Obtain Coverage for Arthritis Injections

Obtaining Medicare coverage for arthritis injections begins with a thorough medical assessment and documentation. Injections must be medically necessary for coverage. This includes a diagnosis of symptomatic osteoarthritis confirmed by imaging, and documentation of previous unsuccessful conservative treatments like physical therapy or pain medication.

Ensure the prescribing physician and facility are Medicare-approved providers who accept Medicare assignment. Some injections may require prior authorization from Medicare or the specific Medicare Advantage or Part D plan. The healthcare provider typically handles this process before the service, confirming the treatment meets coverage criteria. Hyaluronic acid injections for knee osteoarthritis, for instance, often recommend prior authorization.

After administration, the provider typically bills Medicare directly for Part B services. For self-administered Part D injections, fill the prescription at a pharmacy accepting your Part D plan. If a claim is denied, beneficiaries can appeal. The initial step for Original Medicare appeals is a “redetermination” by the Medicare Administrative Contractor (MAC), filed within 120 days of receiving the Medicare Summary Notice (MSN) explaining the denial.

If redetermination is unfavorable, further appeal levels include:
Reconsideration by a Qualified Independent Contractor (QIC).
A hearing before an Administrative Law Judge (ALJ) if the amount in controversy meets certain thresholds.
Review by the Medicare Appeals Council.
Judicial review in a Federal District Court.

Providing supporting documentation, such as medical records and a doctor’s letter explaining medical necessity, can strengthen an appeal. Medicare Advantage and Part D plan appeals may have different initial steps but generally follow a similar multi-level structure.