Does Medicare Cover Knee Surgery? What You Need to Know

Medicare generally covers medically necessary knee surgery, a common procedure for individuals experiencing significant knee pain and mobility issues. This coverage extends to both the surgical intervention and subsequent rehabilitation required for recovery.

Medicare Part A and Part B Coverage

Original Medicare, composed of Part A (Hospital Insurance) and Part B (Medical Insurance), covers knee surgery. Medicare Part A primarily covers inpatient hospital stays, including the operating room, nursing care, and meals during an inpatient admission.

Medicare Part B covers medical services, typically provided in an outpatient setting or by individual providers. This includes surgeon’s fees, anesthesiologist’s fees, and other doctor services for knee surgery, such as pre-surgery consultations and post-operative care. Part B covers outpatient procedures, such as those in an ambulatory surgical center, and associated medical supplies. Part B also covers durable medical equipment (DME) like crutches or walkers, if prescribed.

Understanding Coverage Requirements

For Medicare to cover knee surgery, the procedure must be deemed medically necessary by a healthcare provider. A physician must determine the surgery is appropriate for the patient’s condition, aiming to relieve pain, improve mobility, or address structural issues. Medical necessity involves documentation of advanced joint disease, such as osteoarthritis, confirmed by imaging, and a history of unsuccessful conservative therapies like pain relievers or physical therapy over a period of three months or more.

Prior authorization may be required for certain knee procedures, meaning the healthcare provider must obtain Medicare approval before surgery. Prior authorization ensures the procedure meets Medicare’s medical necessity criteria and helps manage costs. Patients may need a referral from their primary care physician to see specialists, including orthopedic surgeons.

Costs and Financial Responsibilities

Beneficiaries will incur out-of-pocket costs for knee surgery. Under Medicare Part A, there is a deductible per benefit period of $1,676 in 2025. A benefit period begins with an inpatient admission and ends after 60 consecutive days without inpatient hospital or skilled nursing facility care. For hospital stays exceeding 60 days, a daily coinsurance applies: $419 per day for days 61-90 and $838 per day for lifetime reserve days in 2025.

Medicare Part B has an annual deductible of $257 for 2025. After this deductible is met, beneficiaries pay a 20% coinsurance of the Medicare-approved amount for most doctor’s services and outpatient surgery. There is no annual out-of-pocket maximum under Original Medicare (Parts A and B). Medicare Advantage plans (Part C) must cover at least what Original Medicare covers, but they may have different cost-sharing structures, such as copayments and deductibles, and may require using network providers. Medigap (Medicare Supplement Insurance) policies can help cover some of the out-of-pocket expenses, including deductibles and coinsurance, that Original Medicare does not.

Post-Surgery Care and Rehabilitation

Recovery from knee surgery requires post-operative care and rehabilitation. Medicare also covers this. Medicare Part B covers medically necessary outpatient physical therapy and occupational therapy services to regain strength, flexibility, and mobility after surgery. Beneficiaries pay a 20% coinsurance for these services after meeting their Part B deductible.

Durable Medical Equipment (DME), such as crutches, walkers, or knee braces, if prescribed by a doctor for use at home, is covered under Medicare Part B. Medicare pays 80% of the Medicare-approved amount for DME, with the beneficiary responsible for the remaining 20% coinsurance. For short-term skilled nursing facility (SNF) care following an inpatient hospital stay, Medicare Part A provides coverage. To qualify, a patient must have had an inpatient hospital stay of at least three consecutive days and require daily skilled nursing or rehabilitation services. For SNF stays, Medicare covers the first 20 days at no cost, followed by a daily coinsurance of $209.50 for days 21-100 in 2025. Home health care services, including skilled nursing care and therapy provided in the home, may be covered by Medicare after surgery if medically necessary.