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.

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.

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.

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

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 & 14 other states

Answered by Robert Simm 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

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

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

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.

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.

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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