Does Medicare Pay for Knee Braces?
Unravel Medicare's approach to knee brace coverage. Discover how to qualify, acquire, and manage potential claim denials.
Medicare can provide coverage for knee braces under specific conditions. Understanding how Medicare addresses medical equipment like knee braces is important for beneficiaries to receive necessary support.
Medicare Coverage for Knee Braces
Knee braces are covered under Medicare Part B as Durable Medical Equipment (DME). For an item to qualify as DME, it must withstand repeated use, primarily serve a medical purpose, be appropriate for home use, and have an expected lifetime of at least three years. The knee brace must also be medically necessary for the patient’s condition.
Qualifying for Coverage
To be medically necessary and covered by Medicare, a knee brace must be prescribed by a physician or other qualified medical professional. The brace is warranted for conditions such as severe arthritis, post-surgical recovery, or to address knee instability or injury. Objective documentation of knee instability, recent injury, or surgery is required to support the medical necessity.
The physician’s prescription must include specific information. This includes the patient’s diagnosis, the type of brace prescribed, and the anticipated duration of need. Medicare recognizes both “off-the-shelf” and “custom-fabricated” knee braces. Off-the-shelf braces require minimal self-adjustment for fitting, while custom-fabricated braces involve more extensive modification by an expert to fit a specific patient, and documentation must justify the need for a custom item over a prefabricated one.
Acquiring Your Knee Brace
Once the medical necessity for a knee brace has been established and documented by your doctor, the next step involves obtaining the equipment from an approved supplier. It is essential to choose a Durable Medical Equipment (DME) supplier that is enrolled in Medicare. You can locate Medicare-approved suppliers through tools available on the Medicare website, often by entering your zip code and specifying the equipment needed.
A crucial consideration when selecting a supplier is confirming they “accept assignment”. This means the supplier agrees to accept the Medicare-approved amount as full payment for the brace. When a supplier accepts assignment, Medicare pays its share directly to the supplier, and you are only responsible for the Medicare Part B deductible and coinsurance. For 2025, the Medicare Part B annual deductible is $257. After meeting this deductible, you are typically responsible for a 20% coinsurance of the Medicare-approved amount for the knee brace.
Appealing a Denied Claim
If Medicare denies coverage for a knee brace, you have the right to appeal the decision. The Medicare appeals process involves multiple levels, beginning with a redetermination, which is an initial review of your claim. If you disagree with this outcome, you can proceed to the second level, known as reconsideration, where a qualified independent contractor reviews the appeal.
Further levels of appeal include a hearing before an Administrative Law Judge (ALJ), a review by the Medicare Appeals Council, and, as a final step, judicial review in federal district court. It is important to carefully review the denial letter, as it will provide the specific reason for the denial and instructions on how to initiate the appeal process. Submitting supporting documentation from your doctor, detailing the medical necessity, can strengthen your appeal.