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.

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.

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.

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.

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.

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

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 call me at 800-891-5151 or text me at 714-585-8650 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

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

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

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

Answered by Todd Bostic Medicare Insurance Agent

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 call me at 770-712-9990 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

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.

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, NE, UT, WA & WY

Answered by Adam Ashby Medicare Insurance Agent

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

Answered by Leisha Stevens Medicare Insurance Agent

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

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

Answered by Gregory Gudis Medicare Insurance Agent

Charles Mai · Answer

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

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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