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Yes - typically coveredPrior auth: Usually required

Does Oscar Health cover meniscus repair?

Meniscus repair surgery is covered by all major insurance plans when an MRI confirms a repairable tear and the patient has mechanical symptoms (locking, catching, swelling) that have not responded to conservative care. Meniscus repair (where the tear is stitched) and partial meniscectomy (where torn tissue is removed) are both covered, though the specific procedure recommended depends on tear location and patient age.

Quick summary

Coverage

Yes - typically covered

Prior authorization

Usually required

Typical patient cost

With commercial insurance: $700-$2,500. Meniscus surgery is outpatient arthroscopic and typically one of the lower-cost covered orthopedic procedures. Without insurance: $5,000-$12,000 for an outpatient surgery center procedure.

Prior authorization for Oscar

Oscar covers orthopedic office visits, imaging, physical therapy, and surgical procedures as part of ACA essential health benefits. Oscar provides upfront cost estimates for procedures and connects members with in-network orthopedic specialists through their app. Prior authorization is required for elective surgeries.

Always verify your specific Oscar plan before scheduling. Plans within the same insurer (Oscar Health) can have different prior authorization rules, network requirements, and cost-sharing. Call the number on the back of your insurance card or log into your plan portal to confirm coverage for your specific plan.

How to confirm your coverage before scheduling

  1. 1Call Oscar member services (number on back of your insurance card) and ask specifically if meniscus repair is covered under your plan.
  2. 2Ask your orthopedic surgeon's office to verify benefits on your behalf - they do this routinely and can identify in-network requirements.
  3. 3Request the prior authorization criteria in writing if prior auth is required. Ask what documentation is needed from your surgeon.
  4. 4Confirm your deductible remaining for the year - your out-of-pocket cost depends on where you are in the deductible cycle.
  5. 5Get a pre-service cost estimate from the facility if you want a specific dollar figure before scheduling.

What to do if Oscar denies coverage

Insurance denials for orthopedic procedures are common and frequently overturned on appeal. Follow these steps:

  1. 1Provide MRI report confirming the tear with characterization
  2. 2Document mechanical symptoms (locking, giving way, effusion)
  3. 3Note conservative care attempts (PT, NSAIDs, rest)
  4. 4Request peer-to-peer if prior auth is denied

Common questions

Does insurance cover both meniscus repair and partial meniscectomy?
Yes. Both procedures are covered. The choice between them depends on tear type and location (peripheral vascular tears are repairable; central tears usually are not) and is made by the surgeon at the time of arthroscopy based on what is found. Insurance covers the procedure that is actually performed.
Will insurance cover meniscus surgery if I have some arthritis too?
This is where it gets nuanced. Knee arthritis combined with a degenerative meniscus tear (common in patients over 45) is scrutinized more closely. Some insurers require conservative care documentation and have specific criteria for when surgery adds enough benefit to justify coverage. Your surgeon's documentation of mechanical symptoms that cannot be explained by arthritis alone strengthens the prior auth case.

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