Does Medicare Cover Knee Replacement Surgery?

Medicare, a federal health insurance program, provides coverage for millions of Americans, primarily those aged 65 or older, and certain younger individuals with disabilities. Knee replacement surgery is a common orthopedic procedure that alleviates pain and improves mobility for individuals with severe knee conditions. Understanding Medicare’s coverage for this procedure involves navigating its various parts and their benefits.

Medicare Parts and Their Coverage for Knee Replacement

Medicare offers different parts that contribute to knee replacement surgery coverage, depending on the procedure’s location and required services. Each part addresses distinct aspects of medical care.

Medicare Part A, Hospital Insurance, covers inpatient hospital stays. This includes the surgery if performed in an inpatient setting, along with associated costs like room and board, nursing care, and other hospital services.

Medicare Part B, Medical Insurance, covers various outpatient services and professional fees. This includes surgeon’s fees, anesthesia, and other doctor’s services, such as pre-surgery consultations and post-operative care. Part B also covers medically necessary outpatient physical therapy, occupational therapy, and durable medical equipment (DME) like walkers or crutches, essential for recovery.

Medicare Part C, Medicare Advantage Plans, offers an alternative to receive Medicare benefits through private insurance companies. These plans must cover at least everything Original Medicare (Parts A and B) covers, including knee replacement surgery and related services. While comprehensive, Medicare Advantage plans may have different rules, cost-sharing structures, and provider networks than Original Medicare.

Medicare Part D, Prescription Drug Coverage, helps cover medications prescribed during recovery. This includes pain medications, antibiotics, or other drugs needed after knee replacement surgery. These plans are offered by private companies and can be standalone or integrated into Medicare Advantage plans.

Medical Necessity and Eligibility for Coverage

Medicare’s coverage for knee replacement surgery depends on the procedure being medically necessary. This means the service is reasonable and necessary for diagnosis, treatment, or to improve a malformed body part, meeting accepted medical standards. This ensures Medicare resources address a health condition.

To establish medical necessity, specific clinical criteria must be met. Common indicators include severe knee pain or disability that significantly limits daily activities and has not responded to conservative treatments like physical therapy, medication, or injections. A diagnosis of advanced osteoarthritis or rheumatoid arthritis, visible on radiological exams, supports medical necessity.

A doctor must document that the surgery is appropriate and that non-surgical interventions have failed or are not suitable. This documentation is crucial for Medicare approval. Patients must also be enrolled in Medicare Part A and/or Part B for coverage.

Understanding Your Out-of-Pocket Costs

Even with Medicare coverage, beneficiaries incur various out-of-pocket expenses for knee replacement surgery. These costs include deductibles, coinsurance, and copayments, which vary based on the specific Medicare plan.

For inpatient hospital stays covered by Medicare Part A, beneficiaries are responsible for a deductible. In 2025, this deductible is $1,676 per benefit period, which begins the day a patient is admitted to a hospital or skilled nursing facility and ends after 60 consecutive days without inpatient care. If a hospital stay extends beyond 60 days, coinsurance charges apply: $419 per day for days 61-90, and $838 per day for lifetime reserve days.

Medicare Part B covers physician services, outpatient care, and durable medical equipment, requiring a deductible and coinsurance. The annual Part B deductible in 2025 is $257. After meeting this deductible, beneficiaries pay 20% of the Medicare-approved amount for most Part B-covered services. This coinsurance applies to surgeon fees, anesthesia, physical therapy, and durable medical equipment.

Medicare Advantage plans (Part C) feature different cost-sharing structures, such as copayments for services rather than percentage-based coinsurance. These plans also have an out-of-pocket maximum, limiting how much a beneficiary pays for Medicare-covered services in a year. In 2025, the out-of-pocket maximum for in-network services in Medicare Advantage plans may not exceed $9,350. Medigap, or Medicare Supplement Insurance plans, can help cover some or all out-of-pocket costs not paid by Original Medicare, such as deductibles and coinsurance.

The Approval and Post-Surgery Care Process

The procedural steps for obtaining Medicare coverage for knee replacement surgery and managing post-operative care differ based on the Medicare plan. Understanding these processes helps ensure a smoother experience.

For individuals with Original Medicare, formal pre-authorization is not required for medically necessary inpatient hospital stays or physician services related to knee replacement. Healthcare providers verify a patient’s eligibility and coverage details before the procedure. This verification confirms the surgery meets Medicare’s medical necessity criteria.

Medicare Advantage plans frequently require pre-authorization for knee replacement surgery and other significant procedures. Beneficiaries should collaborate closely with their plan and healthcare provider to ensure all necessary documentation, referrals, and authorizations are completed prior to surgery. This step avoids unexpected costs and ensures coverage according to the plan’s rules.

Following surgery, a hospital stay is common. A patient may then be discharged to a skilled nursing facility (SNF) or directly home with home health services. Medicare Part A covers SNF care if specific criteria are met, such as a qualifying hospital stay of at least three days. Part A provides full coverage for the first 20 days in an SNF, with a daily coinsurance of $209.50 for days 21 through 100 in 2025. Medicare Part B covers medically necessary outpatient physical therapy, occupational therapy, and durable medical equipment like canes or crutches prescribed by a doctor for recovery.