Is Meniscus Surgery Covered By Insurance?

The meniscus is a C-shaped piece of cartilage that acts as a shock absorber in your knee joint. Each knee has two menisci – one on the inside part of the knee and one on the outside. The meniscus can become damaged due to injury or general wear and tear as you age. When the meniscus is torn, it can cause knee pain, swelling, and difficulty bending or straightening your knee. If conservative treatments like rest, ice, compression, elevation and physical therapy do not relieve your symptoms, your doctor may recommend arthroscopic surgery to repair or remove the damaged meniscus tissue.

But is this surgery covered by insurance? Here’s what you need to know:

What is Meniscus Surgery?

Meniscus surgery, also known as knee arthroscopy, is a minimally invasive procedure performed through small incisions around the knee. The surgeon inserts a tiny camera, called an arthroscope, to view the inside of the joint and assess the meniscus tear. They then use miniature surgical instruments to trim or sew the torn meniscus depending on the type and location of the tear.

There are two main types of meniscus surgery:

• Meniscectomy – This involves surgically removing the damaged portion of the meniscus. It is done for irreparable tears.

• Meniscus Repair – The surgeon stitches the tear together to heal. This is possible if the tear is in an area with a good blood supply.

Recovery involves keeping weight off the knee for 6 weeks with the help of crutches. Physical therapy helps restore strength and range of motion.

Is Meniscus Surgery Covered By Insurance?

The answer is usually yes. Most health insurance plans cover medically necessary meniscus surgery. This is because repairing or removing torn knee cartilage is required to restore normal knee function and mobility which is impaired by the injury.

Here are some points on getting insurance coverage for your meniscus surgery:

• Meniscus surgery is typically covered by most major medical insurance plans including Medicare, Medicaid, and private health insurance.

• The procedure must be deemed medically necessary by your orthopedic surgeon and insurance company. Symptoms like persistent knee pain and difficulty walking support medical necessity.

• Your insurance may need documentation from your doctor explaining the extent of the tear, treatments tried and recommendation for surgery.

• Make sure your surgeon and surgical facility are in-network providers under your health plan. This will help maximize your coverage and savings.

• Contact your insurance company to find out details of your meniscus surgery coverage including deductibles, copays, coinsurance and any prior authorization requirements.

What Meniscus Surgery Costs are Covered?

Once approved, health insurance can cover various direct costs of knee arthroscopy:

• Surgeon fees – This is your orthopedic surgeon’s charge for performing the meniscus surgery.

• Hospital or facility fees – This covers the operating room, surgical equipment, supplies and nursing care you receive on the day of surgery.

• Anesthesia fees – This is for the anesthesiologist who administers general anesthesia or a nerve block during the procedure so you don’t feel any pain.

• Diagnostic testing – X-rays, CT scan or MRI of the knee needed to diagnose the tear may be covered.

• Physical therapy – Many plans include post-op rehab for a limited time.

• Surgical supplies and devices – This includes tools like the arthroscope, small surgical instruments, surgical drapes, etc.

Any facility or physician charges, tests or aftercare related to the surgery that your insurance policy covers will be paid for up to the benefit limits of your plan, after you meet your deductible.

Typical Out-of-Pocket Costs

Though insurance subsidizes the total costs, you will still have to pay some surgical expenses out of your own pocket. These usually include:

• Annual deductible – The fixed amount you pay before insurance starts paying benefits. It can range from $1,000 to $2,500 for individual coverage.

• Coinsurance – Your share of the costs after you meet the deductible, often 10-30%.

• Copay – A fixed amount you pay when you receive medical care, like $30 for seeing a specialist.

• Charges above usual and customary rates – If your provider’s fees exceed what is considered typical in your geographic area, you may have to pay the difference.

• Cost of non-covered services – Expenses for optional or non-essential items may not be covered. e.g. knee braces.

Getting an estimate of the total costs beforehand can help you budget for these expenses. Talk to your insurance company and surgeon’s billing office to get more clarity.

Ways to Reduce Your Out-of-Pocket Costs

• Use in-network providers – Surgeons and hospitals within your plan’s network offer better coverage at lower negotiated rates to cut down your share of the bill.

• Ask about cash pricing – Some facilities provide discounts when you pay the entire bill upfront in cash.

• Negotiate costs beforehand – You can try negotiating costs of any uncovered services directly with your healthcare providers.

• Use tax-free savings accounts – Paying with a Health Savings Account (HSA) or Flexible Spending Account (FSA) allows you to pay with tax-free dollars.

• See if discounts are offered – Some providers give prompt payment discounts if you pay your bill quickly.

What if Meniscus Surgery is Not Covered?

In some cases, meniscus surgery may be considered not medically necessary and denied coverage if:

• Your symptoms are mild and don’t limit activity. Conservative treatment is recommended first.

• You have severe arthritis and surgery is unlikely to help knee function.

• The tear is in an area that cannot be repaired. Partial removal will not benefit you.

• You had a meniscus surgery on the same knee recently. Repeat surgery soon after may not be approved.

If your claim gets denied, don’t hesitate to appeal the decision with more information from your orthopedic surgeon. Most appeal at least once, and many insurers overturn the initial denial.

If it still doesn’t get approved, call the insurance company to discuss payment plan options. Self-pay discounts may also be offered by the healthcare facility.

The Takeaway

Meniscus surgery is usually covered by health insurance, but the specifics depend on your individual policy. Confirm coverage details with your provider. Getting preauthorization and using in-network providers is key to minimize out-of-pocket expenses. With proper documentation from your orthopedic surgeon, surgery for a torn meniscus meets the criteria for medical necessity in most cases.