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Yes - typically coveredPrior auth: Always required

Does Oscar Health cover total knee replacement?

Total knee replacement is covered by virtually all major insurance plans when medically necessary - meaning conservative treatment (physical therapy, injections, NSAIDs) has been tried and has not provided adequate relief. Prior authorization is required by most commercial insurers and Medicare Advantage plans. Original Medicare does not require prior auth but does review claims for medical necessity.

Quick summary

Coverage

Yes - typically covered

Prior authorization

Always required

Typical patient cost

With commercial insurance, patient out-of-pocket typically runs $1,000-$4,000 depending on deductible and plan. Medicare with Medigap Part A covers the inpatient hospital stay with a per-benefit-period deductible (~$1,700 in 2026). Without insurance, hospital-billed charges for knee replacement often exceed $40,000.

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 total knee replacement 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. 1Request a written denial letter specifying the denial reason
  2. 2Ask your surgeon's office to request a peer-to-peer review with the insurance medical reviewer
  3. 3Gather documentation of failed conservative treatment (PT records, injection notes, imaging reports)
  4. 4File a formal internal appeal within 30-180 days depending on plan type
  5. 5Request an external independent review if internal appeal is denied
  6. 6Contact your state insurance commissioner if the plan continues to deny a clearly necessary procedure

Common questions

Does insurance cover knee replacement if I am under 60?
Yes. Most insurers base coverage on medical necessity, not age. Severe arthritis or post-traumatic knee damage in a younger patient is covered the same way as in an older patient, as long as conservative treatment has been tried and documented.
Will insurance cover the physical therapy after knee replacement?
Yes. Post-operative rehabilitation is a covered benefit under all major insurance plans, subject to annual visit limits (typically 30-60 visits). Prior authorization for PT may be required after a set number of sessions.
Can insurance require me to try injections before approving surgery?
Some plans include step-therapy requirements where conservative treatments must be tried and documented first. Corticosteroid injections, hyaluronic acid injections, and physical therapy are most commonly required. Requirements vary by plan and are typically specified in the prior authorization decision.

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