I called to ask about a knee replacement and suddenly they said I need prior authorization. I thought my plan was supposed to be good-what's going on?

Question

Thomas Ashton · Accepted Answer

If you have a Medicare Advantage plan thy could ask for a prior authorization. It also could depend on the healthcare provider, or weather it is an HMO or a PPO.

Mark Bilgere · Answer

It depends on what type of plan you have and the carrier. If you have a Medicare supplement, you should not need proof authorization if your doctor recommends the surgery. If you have an Advantage Plan then prior authorizations are common for larger surgeries. No plan is all good or all bad. They all have different features. Stay persistent and be your own advocate.

Answered by Mark Bilgere on August 2, 2025

Broker Licensed in TX, AR, IN & LA, MN, NE & OK

Answered by Mark Bilgere Medicare Insurance Agent

Daniel Brechin · Answer

Certain procedures do require prior authorization.   The Dr will handle that for you.
Prior authorization is generally handled between the Dr office and the company.
Danny

William Lawler · Answer

The question was about prior authorization. Prior authorization is no big deal. Many plans have what they call prior authorization. This is just giving a procedure authorization before going forward, which is always good news. You don't want to get this procedure done and then have the insurance company deny it. So, prior authorization is a good idea, and it lets you know going forward whether the insurance company is going to pay for it or not.

Larry Dalton · Answer

When you choose Traditional Medicare Parts A and B, along with Medigap Plan G, you benefit from comprehensive coverage without any out-of-pocket expenses after meeting the Medicare Part B annual deductible of $285 in 2025. This plan offers the flexibility to receive healthcare services from a variety of locations without any restrictions.

In contrast, Medicare Advantage plans could require preapproval for surgeries, and the care must be coordinated through your primary physician. Typically, the services are obtained within designated PPO or HMO network facilities.  It's important to note that out-of-pocket expenses are associated with these surgeries under these plans, unless specified otherwise within the chosen Medicare Advantage insurance carrier’s plan.

Ann Sanfelippo · Answer

I understand your concern — some procedures, like knee replacements, require prior authorization to ensure they’re medically necessary and covered under your plan’s guidelines. This doesn’t mean your plan isn’t good; it’s a standard step to help manage costs and make sure you receive the right care.

Answered by Ann Sanfelippo on October 5, 2025

Broker Licensed in FL, AL, AZ & 14 other states

Answered by Ann Sanfelippo Medicare Insurance Agent

Vincent Murray · Answer

On an HMO your doctor simply fills out a Prior Authorization, it is easy.  Your doctor does it not you.  If this bothers you, simply choose a PPO plan in your area to avoid this issue.

Nikki Rowland · Answer

Without know what kind of plan you have, this is a tough question to answer.  More info is needed. Some plans require pre-auth and some do not.

Nick Mangini · Answer

This is because you probably have a Medicare Advantage plan and they are the primary payor! You do not have Medicare as your primary payor! You should have Medicare & Supplement Plan (Medigap) so you don't have to worry about prior authorization.

Answered by Nick Mangini on March 29, 2026

Broker Licensed in FL, AL, AZ & 32 other states

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Don Hudson · Answer

Most plans require Step Therapy. This process is to ensure the surgery is the last option.
Step therapy may include shots and or Rehab.

Ellen Diehl · Answer

Who told you you were "good"? where they a licensed broker or an 'agent' at an 800 number? If I had to guess I bet you used to be on a Supplement Plan G and now you are on an Advantage plan that can delay care. ask the person who sold it to you about what is going on. or you can contact me and I should be able to identify the problem. You won't be able to make any changes until AEP. Ellen

Answered by Ellen Diehl on April 13, 2025

Broker Licensed in GA

Answered by Ellen Diehl Medicare Insurance Agent

Marsha Reiniers · Answer

Medicare does not typically require prior approval for surgery, however, there are different types of plans, so your plan may require pre- approval. With a Medicare Supplement plan, prior authorization is not required, however, with some Medicare Advantage plans (managed health plans) a prior authorization may be required. You should consult with your particular plan for more information.

Answered by Marsha Reiniers on April 1, 2026

Agent Licensed in FL, GA, MI & NC, PA, SC & VA

Answered by Marsha Reiniers Medicare Insurance Agent

Cheri Rogers · Answer

The answer to this question without depends on the Medicare Insurance you have. Do you have a Medicare Advantage Plan or Medicare Supplement? 
If you are on a Medicare Advantage plan all surgeries must be pre-auhorized. If you are on a Medicare Supplement and the surgery has been apprpved by Medicare then the Medicare Supplement will cove it as well.

Jason Denniston · Answer

It definitely catches people off guard, but this is actually pretty normal, even on strong plans.

Prior authorization just means your insurance company wants to review the procedure ahead of time to make sure it meets their medical necessity guidelines. It’s something almost all health insurance plans do to help control costs and keep premiums from rising more than they have to.

The good news is, you usually don’t have to handle this yourself. Your doctor’s office will send in the information and work directly with the insurance company to get a decision.

If it ends up being denied, you have the right to appeal that decision.

And if the process feels confusing or stalls out, this is a great time to loop in your broker. They can often help figure out what’s missing and keep things moving in the right direction.

Robert Simm · Answer

Prior authorization should be between your providers and your insurance company. Your providers are responsible to sending out the correct CPT codes so this particular procedure can be approved and then completed by your doctor's office. If your doctor's office is calling you a letting you know that you need prior authorization and then that is incorrect information. The doctor's office is always responsible for these prior-auth medical services.

Answered by Robert Simm on April 8, 2025

Broker Licensed in NC, AL, AR & 15 other states

Answered by Robert Simm Medicare Insurance Agent

Daniel Maisel · Answer

That is a good question.

Getting prior approval is not necessarily bad.

I am a big believer in getting second options. Often the one they are reviewing your needs are more knowledgeable. They may also know of other ways of caring for your issue previously not considered.

Example: I was told I had a torn rotator cuff. I received approval for another viewpoint. That doctor suggested I have physical therapy.

I did not understand, thought the first opinion of surgery made sense.

Result: After following the physical therapy my sharp cutting disappeared and I can now play ball with my grandchildren.

Have an open mind, be patient.

Adam Ashby · Answer

Depending on the plan that you are on your carrier may have steps that you must complete to ensure that a knee replacement is required and the best possible solution for your needs. Requiring prior authorization does not automatically mean that the procedure will be denied, only that the carrier you have chosen can verify best practices have taken place. The fact that different carriers have different requirements is exactly why you want to visit with a Medicare Broker who represents several different carriers each and every year. Make sure that you and your doctors have the capability to make the best decisions for you.

Answered by Adam Ashby on May 27, 2025

Broker Licensed in CO, GA, IL & 6 other states

Answered by Adam Ashby Medicare Insurance Agent

Phillip Davis · Answer

Different carriers require pre-requisites for certain procedures. Your summary of benefits should be able to break this down for you.

Roger Werking · Answer

Knee replacement is very expensive, so the insurance company wante to confirm that the replacement is really necessary, and that conservative treatments were treid first.

Sherry Stone · Answer

In general, all insurance plans will require prior authorization for surgical procedures, and there can be several reasons for this. Cost is always high on the list. The insurer will want to make sure the procedure is medically necessary, if the surgery is the most appropriate course of action, and if less expensive options have been explored first.

Answered by Sherry Stone on October 10, 2025

Agent Licensed in IA & IL

Answered by Sherry Stone Medicare Insurance Agent

Jon Kelderman · Answer

Insurance companies and in particular Medicare Advantage companies can use prior authorization. Typically, Medicare supplement or Original Medicare do not have prior authorization. Your plan no matter which type is required to cover that same things as original Medicare. Prior authorization is used to make sure the Doctor is using the most effective treatment for your condition. That by the way is putting it in the most positive light. There are differing opinions as to whether that is what prior authorization is accomplishing.

Answered by Jon Kelderman on June 24, 2025

Broker Licensed in IA, AZ & TX

Answered by Jon Kelderman Medicare Insurance Agent

Marc Butler · Answer

Many insurance companies require prior authorizations for major surgeries I.e like a knee replacement. This is quite common

Ronald Plocinski · Answer

Not to worry! A prior authorization isn't designed to show a plan to be a good one as opposed to a bad one but rather, is the plan efficiently using the funding in a way that best keeps you in a state of good health. A Prior Authorization is a normal step in managed care Medicare plans and their goal to keep you in good health.

Answered by Ronald Plocinski on September 14, 2025

Broker Licensed in NH, AZ, CA & 16 other states

Answered by Ronald Plocinski Medicare Insurance Agent

Mark Michael · Answer

Most Medicare advantage, health, maintenance organizations HMO's require prior authorizations.  It's a benefit to you as it assures you're working with the network build. the doctor and the facilities.  If out of network, you may be required to pay the full bill.  
Which could add up to tens of thousands of dollars.

Ja&#039;el Michael · Answer

If you have a Medicare Advantage Plan or Part C, these plans mean your primary insurance is no longer Medicare, but rather the company on your member card. Typically these companies ask for Prior Authorizations as an additional step to verify the necessity of many procedures.  If you have one of these, the best thing is to ask that the prior authorization be sent in as "expedited" for a roughly 72 hour response. Otherwise, it can take 14 days or so for it to process. 

If you would like as little red tape as possible, so less need for prior authorizations. You may want to consider staying with original Medicare as your primary, then adding a supplement/ medigap plan G for secondary coverage with a stand alone prescriptions drug plan. This way Medicare pays 80%, your supplemental plan G picks up the other 20% (after the part B deductible). As long as Medicare approves it, the supplemental plan must pay their part too. AND you have the flexibility to go to any doctor accepting Medicare across the country.

Steven Bleicher · Answer

Due to the rate of inflation that is being predicted, Medicare insurance firms are cracking down on expensive procedures. This means that their underwriting dept wants to review the doctor's notes as to the severity of pain before agreeing to the operation. This mostly occurs with Advantage plans rather than a Medigap.

Answered by Steven Bleicher on May 29, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Andrew Zurbuch, MBA · Answer

Depends on what type of Medicare Insurance you have. Original Medicare with a Medigap Insurance Policy, a Medicare Advantage Policy, Group Health Insurance coverage, VA Benefits, or FEHBA coverage. Yes, some Medicare Advantage claims require Prior Authorization. Call 1800MEDICARE for Original Medicare or contact your Broker for assistance. Thank you.


Plans are insured or covered by a Medicare Advantage (HMO, PPO and PFFS) organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Diana Garner · Answer

I understand your frustration. Still, prior authorizations are a common process for your insurance company to review the treatment plan to ensure it is medically necessary and appropriate before approving the coverage.  

Certain procedures, such as ones with high costs or considered to be elective, often require approval.

Jim Tretola · Answer

If you have a Medicare Advantage Plan, this is a standard procedure, as it is "Managed Care", and why Premiums are often $0 or very low. If this doesn't work for you, and you can afford it, you might consider a Medicare Supplement Plan.

Answered by Jim Tretola on November 4, 2025

Broker Licensed in NJ, CA, CT & 6 other states

Answered by Jim Tretola Medicare Insurance Agent

Priscilla Ramos · Answer

Even if your plan covers it, many insurers require prior authorization to confirm the surgery is necessary, with an approved provider, and costs will be covered. It’s a standard step, not a problem with your plan.

Answered by Priscilla Ramos on March 28, 2026

Agent Licensed in OH, AZ, FL & 5 other states

Answered by Priscilla Ramos Medicare Insurance Agent

Steven A James, MBA · Answer

You plan should cover but nearly all surgeries require PA.  Doctors/hospitals are going to confirm it's in place before any procedures to ensure follow up payment.  Even Medicare requires PA as procedures must be deemed "Medicare medically necessary" to be covered.

Steven A James, MBA
Contact me.

Hannah Skinner · Answer

You likely live in one of the six states where the WISeR program was implemented. 

The WISeR program is a government performance model that's goal is to reduce Medicare fraud and waste. It will run from January 1st, 2026 to December 31st, 2031 in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

You can learn more by going to CMS.gov and looking under Innovation models.

Richard Kozlowski · Answer

Prior authorization is a process used by health insurance companies to determine if they will cover a specific medical service, procedure, or medication.

Purpose of Prior Authorization

Cost Control: Insurers use it to manage healthcare costs and ensure that treatments are medically necessary.
Quality Assurance: It helps ensure that patients receive appropriate care based on clinical guidelines.
How It Works

Request Submission: Healthcare providers submit a request to the insurer detailing the proposed treatment.
Review Process: The insurer reviews the request against established criteria and guidelines.
Decision Notification: Providers and patients are informed of the decision, which can be approval, denial, or a request for additional information.
Common Areas Requiring Prior Authorization

Specialty Medications: Often high-cost drugs that require careful management.
Certain Procedures: Surgeries or advanced imaging tests may need prior approval.
High-Cost Treatments: Treatments that are expensive or experimental typically require authorization.
Challenges

Delays in Care: The process can lead to delays in treatment, which may affect patient outcomes.
Administrative Burden: It adds extra steps for healthcare providers, potentially complicating patient care.
Variability

Requirements for prior authorization can vary significantly between insurers and plans, leading to confusion for patients and providers.

Donald Elliott · Answer

Most Medicare Advantage plans require prior authorization for major medical procedures. This is generally very simple. In most cases your doctor should have submitted this prior to scheduling

Nickey Baxter · Answer

Most insurance companies will ask for a procedure to be authorized. This helps both you and the insurance company as it will tell you that it is covered in network, so you don't end up with a surprise out of pocket expense. In addition, the insurance companies look at medical history, to make sure it is a necessary surgery or procedure. Elective procedures are not covered by insurance.

Answered by Nickey Baxter on October 18, 2025

Broker Licensed in UT, AZ, CO & 18 other states

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Fred Manas · Answer

Prior authorization for a knee replacement means your insurance plan requires your doctor to get pre-approval before the surgery. This is a common requirement for higher-cost procedures like knee replacement, often to ensure it's medically necessary and to manage costs. 
Here's a breakdown of why this might be happening:
Cost-Control:
Insurance companies and government agencies (like Medicare) use prior authorization to manage costs and ensure that treatments are medically necessary and not unnecessarily expensive, says the Center for Medicare Advocacy. 
Medical Necessity:
Prior authorization helps determine if the knee replacement is medically necessary given your condition and other treatment options. 
Plan Specifics:
Your insurance plan may have specific rules regarding prior authorization for procedures like knee replacement, even if your plan appears to cover it, according to Verywell Health. 
Medicare Advantage:
If you have a Medicare Advantage plan, prior authorization is more likely than with Original Medicare (Parts A and B), especially for higher-cost services like surgery, says Healthline. 
Interpreting "Good" Coverage:
The term "good coverage" can be subjective. While your plan might cover knee replacement, it could still require prior authorization, which is a standard process for many plans,

Gary Henderson · Answer

All medical procedures require a doctor provide information that makes it medically necessary 
For example, if you decide you want a knee replacement, you just can't get one because you want it. You're not a medical professional

Andrew Kramer · Answer

What's the meaning of "good-what's going on?" No matter what plan you have - original Medicare with a supplement, Medicare Advantage PPO or HMO, you just can't get some kind of major medical, i.e. MRI, surgery, etc, covered without getting prior authorization! Think about it rationally... can you just walk into an imaging center and say, "I want an MRI of my knee and I want my insurance plan to pay for it?" A request for "auth" to your plan, must have documentation from your provider for the need for, in this case, a knee replacement. My clients often get referrals and auths mixed up. They are not the same!

Answered by Andrew Kramer on June 1, 2026

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Meghan Blankenship · Answer

Even if your Medicare plan is highly rated, prior authorization is a common requirement - especially if you're enrolled in a Medicare Advantage (Part C) plan. These plans are managed by private insurance companies and often require approval before covering certain procedures, like a knee replacement.

Answered by Meghan Blankenship on November 14, 2025

Broker Licensed in FL, MD & OH

Answered by Meghan Blankenship Medicare Insurance Agent

Carol Thompson · Answer

That depends on which plan you are on, calling member services of your plan will be able to help you out.

Mark Boone · Answer

Most likely you have a Medicare Advantage plan and prior authorizations are common. The insurance company just wants to make sure its medically necessary and that all other options have been reviewed. Getting a prior authorization shouldn't be that difficult. The surgeon just needs to submit a request that it's a medically necessary operation and it's usually granted. Just because you are being asked to get prior authorization does not mean your plan is bad.

Answered by Mark Boone on November 8, 2025

Agent Licensed in MN, FL, MI & NC, OH, SC & VA

Answered by Mark Boone Medicare Insurance Agent

Suzanne Lamperti · Answer

That depends on the plan you're enrolled in. Some require ore authorization and some don't.  You need to check with your plan. If you need preauthorization, ask what needs to be done, ( the process).

Todd Bostic · Answer

Your plan probably does cover knee replacement, but it also requires your insurance to approve it first. So, simple answer is "yes" it will be covered, but they want to ok it first. There might be an extenuating circumstance that would prevent them from covering it.

Answered by Todd Bostic on May 28, 2025

Broker Licensed in TX, AL, AZ & 12 other states

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Mike Henry · Answer

When you’re on Medicare you must have prior authorization. Doctors recommended and Medicare approved. Those are the rules

Jack Mayer · Answer

All Medicare Advantage Plans have a PCP and you must have prior authorization unlike original Medicare, also many plans have done away with PPO's where you can see a specialist in network without a referral but due to heavy utilization most plans only offer HMO and therefore you need prior authorization

Answered by Jack Mayer on March 16, 2026

Agent Licensed in CA & NV

Answered by Jack Mayer Medicare Insurance Agent

Dean Chiapetto · Answer

Well you can't just go to the orthopedic and ask for a knee replacement. Your PCP will need to start the process and refer you to a surgeon. This is common no matter what type of insurance you have, also it is standard business practice for the doctors. 
Brokers Make a Difference!

Carol Conner · Answer

If you have an HMO or PPO, you’re gonna have to have a referral or you have any kind of specialty doctor involved so your insurance agent should have discussed what type of plan you were on and what the benefits were

Answered by Carol Conner on January 19, 2026

Broker Licensed in TX

Answered by Carol Conner Medicare Insurance Agent

Don Hansford · Answer

The prior authorization process is in place to protect you and the integrity of the Medicare program. It goes a long way in preventing fraud along with reducing the number of unnecessary procedures. As long as the procedure is deemed "medically necessary", it will be covered.

Answered by Don Hansford on November 4, 2025

Broker Licensed in TX

Answered by Don Hansford Medicare Insurance Agent

Mel Stevens · Answer

Medicare plans are good plans and prior authorization is a standard for many procedures in this day and age. Many procedures require prior authorization because they are costly and the insurance carrier needs to complete due diligence to make sure procedures are medically necessary. This helps keep insurance rates and benefits within the plan to remain competitive for all.

Answered by Mel Stevens on April 9, 2025

Broker Licensed in AZ

Answered by Mel Stevens Medicare Insurance Agent

Glenn Alterman · Answer

Yes, u need to have it approved by the carrier unless you have a supplement. Did you switch to an Advantage Plan? I am sure your agent told you this and if not please contact me or text me and I will assist you

Answered by Glenn Alterman on April 20, 2025

Broker Licensed in TX, AZ, CA & FL, NJ, OH & TN

Answered by Glenn Alterman Medicare Insurance Agent

Claudia Englert · Answer

The insurance companies require prior authorizations for surgeries & certain other procedures as well as certain outpatient prescription drugs, especially the expensive drugs & procedures. They normally don’t take a long time to approve them, usually within just a couple of days maximum.

Answered by Claudia Englert on November 14, 2025

Broker Licensed in OH

Answered by Claudia Englert Medicare Insurance Agent

Robin Duffey · Answer

Since I am not sure which Medicare plan you are on I can give you general information.
If you have a Medicare Advantage plan, you will always need authorization whether you have a PPO plan or an HMO plan.  Referrals are different from authorizations and sometimes come from the carrier's network.  If you have Original Medicare and a supplement plan you do not need authorizations BUT in AZ and two other states for next year there will be 10 surgeries that will require authorizations (they have not shared which surgeries / health issues these will be yet) as a testing ground... that is a wait and see.

Not sure if this helped answer your question but hopefully did a bit :) robin

Albert Smith · Answer

Most plans require you to get a referral from your Primary Care doctor. Usually, a specialist is the physician doing the surgery and wants to get paid.

Michael Gilman · Answer

It makes sense to feel confused when you’re told you need prior authorization for something big like a knee replacement. With Medicare Advantage plans, this is totally normal — they check major procedures ahead of time to make sure everything is medically necessary. Your doctor’s office usually sends in all the paperwork.

This is also why choosing the right kind of Medicare matters. Medicare Advantage plans usually cost less each month, but they use prior authorizations and networks. Original Medicare with a Supplement costs more monthly, but you can go to any doctor that takes Medicare and you usually don’t deal with prior authorizations for medically necessary care. Neither one is “better”  they just work differently, and it’s about what fits you best

Leisha Stevens · Answer

It sounds like your doctor's office is requiring prior authorization for your knee replacement surgery. This is a common procedure, and it essentially means your insurance needs to approve the treatment before it's performed. Prior authorization helps insurance companies determine if the procedure is medically necessary and covered by your plan, ensuring you aren't unexpectedly billed for the cost.

Answered by Leisha Stevens on May 19, 2025

Broker Licensed in OH, CA, FL & NC

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Charles Mai · Answer

Some treatments will require prior authorization.  Just work with your doctor to get it.  They are usually approved.

Brian Loquist · Answer

99 % of procedures will go through Prior Authorization. Expect to go through a prior authorization process for a knee replacement if you have a Medicare Advantage plan. Work closely with your doctor and your plan to ensure a smooth process.

Answered by Brian Loquist on May 28, 2025

Agent Licensed in SC, GA, NC & SD

Answered by Brian Loquist Medicare Insurance Agent

Tammy Monjaras · Answer

Many Medicare Advantage plans require pre authorization before surgery. It doesn’t mean you have a bad plan.

Gregory Gudis · Answer

Without knowing your plan and whether it is Medicare with a Supplement or Medicare Advantage, this is a difficult question to answer. While Original Medicare does not usually require prior authorization (usually meaning they still can), Medicare Advantage plans would be more likely to.

Answered by Gregory Gudis on April 28, 2025

Broker Licensed in AZ, CO, CT & 16 other states

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George Santangelo · Answer

Any Medicare advantage plan even ppo needs prior approval from the plan itself. However if u need it they should authorize it. Medicare supplements won’t need it

Jessica Yen Le · Answer

Please rest assured. That’s understandable and common. Even with good coverage, most plans require prior authorization for knee surgery. Since not every case is the same, what I can suggest now is requesting your doctor to submit approval paperwork, and you can confirm coverage with your insurance.

Answered by Jessica Yen Le on November 7, 2025

Broker Licensed in CA, AK, AZ & 24 other states

Answered by Jessica Yen Le Medicare Insurance Agent

Wayne Creeden · Answer

You probably have an HMO. You need to call IRACARE.  They can go over the options that you have, and compare what you have.

I called to ask about a knee replacement and suddenly they said I need prior authorization. I thought my plan was supposed to be good-what's going on?

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I called to ask about a knee replacement and suddenly they said I need prior authorization. I thought my plan was supposed to be good-what's going on?

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