Insurance coverage for orthopaedic procedures is straightforward in theory and bewildering in practice. Your plan "covers" surgery, but the bill still arrives with numbers that don't match anything you expected. Here's how to navigate it.
What Insurance Typically Covers
Most commercial plans and Medicare cover orthopaedic surgery when it's "medically necessary." That phrase does a lot of heavy lifting. In practice, it means your surgeon has documented that conservative treatments (physical therapy, injections, bracing, medication) failed to resolve the problem, and imaging (X-ray, MRI) confirms a structural issue that warrants surgical intervention.
Generally covered without much hassle:
- Office visits and consultations
- X-rays and MRIs (though some plans require prior auth for MRI)
- Physical therapy (with visit limits - check your plan)
- Joint replacement (knee, hip, shoulder) after failed conservative care
- Fracture repair (emergency - usually no prior auth needed)
- ACL reconstruction, rotator cuff repair, meniscus surgery
Harder to get approved:
- Spinal fusion (extensive documentation required, sometimes independent review)
- Repeat surgeries on the same joint
- Experimental or newer techniques (robotic surgery is generally covered, but check)
- Second opinions (covered by most plans, but confirm)
The Prior Authorization Game
Prior authorization is the insurance company's way of confirming the procedure is medically necessary before they agree to pay for it. Your surgeon's office handles the paperwork, but here's what you should know:
Timing matters. Getting prior auth can take 5 to 30 business days. Don't schedule surgery until authorization is confirmed in writing. Verbal approvals mean nothing.
Denials happen. If your authorization is denied, your surgeon's office can appeal. Common reasons for denial: not enough conservative treatment documented, imaging doesn't match the diagnosis code, or the procedure is considered "not medically necessary" by the reviewer (who is often not an orthopaedic surgeon). Appeals overturn denials roughly 40-50% of the time.
The surprise bill scenario: your surgery is approved, but the anesthesiologist or assistant surgeon is out-of-network. The No Surprises Act (2022) protects you from balance billing in emergency situations and at in-network facilities, but verify that ALL providers involved in your surgery are in-network.
Questions to Ask Before Surgery
Call your insurance company (the number on the back of your card) and ask:
1. "Is this procedure covered under my plan?" (Get the procedure code - CPT code - from your surgeon's office)
2. "Has prior authorization been approved?" (Get the auth number)
3. "What is my out-of-pocket maximum for this plan year?"
4. "Is the surgeon in-network? Is the facility in-network? Is the anesthesiologist in-network?"
5. "How many physical therapy visits are covered per plan year?"
6. "Does my plan cover durable medical equipment?" (walker, brace, CPM machine)
Write down the name of the representative, the date, and a reference number for the call.
Medicare Specifics
Medicare Part A covers the hospital stay. Part B covers the surgeon fee and outpatient services. You pay the Part A deductible (about $1,632 in 2024) and 20% of the Part B-approved amount.
If you have a Medigap (supplemental) policy, it may cover most or all of the remaining 20%. If you have Medicare Advantage, coverage depends on your specific plan and network.
The 3-day rule (if applicable): Traditional Medicare requires a 3-day qualifying hospital stay for skilled nursing facility coverage after surgery. Medicare Advantage plans may have different rules. Ask.
The Bottom Line
Insurance covers most orthopaedic surgery when you have documentation of failed conservative treatment, proper imaging, and prior authorization. The system is annoying but navigable. Don't skip the verification calls. Don't assume anything. Get everything in writing.