Does Medicare Cover Knee Gel Injections?

If you’re living with osteoarthritis in your knees, you know how difficult and painful it can be. Today in the United States, over 50 million people have osteoarthritis and many live with pain, stiffness, loss of flexibility, bone spurs, swelling and tenderness, and a general reduction in their day-to-day quality of life. 

Medicare Benefits Solutions

Apr 17, 2021

 4 minutes read

In cases of severe knee osteoarthritis, many physicians may suggest either having knee replacement surgery or treatment with gel injections in the knee. The gel injection treatment is non-invasive and helps by temporarily relieving the pain and restricted mobility that comes with osteoarthritis. While in most cases, people eventually require replacement surgery, getting knee gel injections could be a great option for the relief of your symptoms. 

Knee gel injections, also known as viscosupplementation, are gels that consist of hyaluronic acid, a substance found naturally in the synovial fluid around all the joints. A supplement of this fluid, injected into the knee, can provide better lubrication and cushioning so the joint bones don’t rub together.
If your health care provider has mentioned knee gel injections as a treatment option to limit the pain and increase mobility, you might be concerned about your Medicare insurance coverage. Here’s a look at how your Medicare benefits could cover the cost.

Does Medicare cover knee gel injections?

If you have Original Medicare Part B (medical insurance) or a Medicare Advantage (Part C) plan, your benefits include coverage of knee gel injections if you are eligible. To meet the requirements for eligibility, you must meet the following requirements:

• The injections are for the knees only
• You show evidence of knee osteoarthritis with X-rays
• Coverage is acceptable for injections given no more often than every six months
• Your Medicare-affiliated health care provider must certify that the injections are medically necessary. 

To meet the requirement of medical necessity, certain conditions apply. You are experiencing knee pain due to osteoarthritis, regardless of whether the pain is accompanied by stiffness and swelling. Knee pain doesn’t respond to other forms of therapy like weight loss or physical therapy. Knee pain doesn’t respond to over-the-counter drugs like nonsteroidal anti-inflammatory medications.

Your Medicare Part B benefits cover the cost of your knee gel injections if the administering health care provider accepts Medicare assignment and they are given in their medical facility or office or as an outpatient in a hospital. The health care provider who administers the injections is the one who purchases the medication, you don’t buy it yourself.

To meet the requirement of medical necessity, certain conditions apply. You are experiencing knee pain due to osteoarthritis, regardless of whether the pain is accompanied by stiffness and swelling. Knee pain doesn’t respond to other forms of therapy like weight loss or physical therapy. Knee pain doesn’t respond to over-the-counter drugs like nonsteroidal anti-inflammatory medications.

Your Medicare Part B benefits cover the cost of your knee gel injections if the administering health care provider accepts Medicare assignment and they are given in their medical facility or office or as an outpatient in a hospital. The health care provider who administers the injections is the one who purchases the medication, you don’t buy it yourself.

Your Medicare Part B benefits cover 80 percent of the final, approved cost of the injections and their administration. You pay the remaining 20 percent as well as your Part B deductible.

If you have coverage with a Medicare Advantage plan, in most cases you must use health care providers, medical facilities, hospitals, and pharmacies that are within your private insurance plan’s network. If you go outside the network, you may have to pay 100 percent of the cost. If you don’t know who is included in the plan’s network, read the policy carefully, or call your provider and ask a representative there.

How much do knee gel injections cost without Medicare insurance?

There are several brands of knee gel injections on the market these days and your out-of-pocket cost per injection depends first on the brand you choose. Your cost also depends on where you live and who administers your injection. In the United States, the estimated national average cost for one knee gel injection is $1,012.00. 

If your health care provider recommends that you get gel injections to relieve your knee pain and mobility issues, you should do your homework and make a decision based on what’s best for your circumstances. If you have more questions about your Medicare coverage for the injections, you can speak to your physician or a representative of your Medicare plan.

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