If you’ve been diagnosed with a torn meniscus, you may be wondering if surgery to repair or remove the damaged cartilage will be covered by your health insurance plan. Thankfully, the answer is usually yes – most insurance policies provide coverage for medically necessary meniscus surgery.
In this comprehensive guide, we’ll explain everything you need to know about insurance coverage for meniscus repair and partial meniscectomy procedures We’ll outline the costs involved, which plans typically cover surgery, and tips for getting the maximum coverage.
Why Insurance Usually Covers Meniscus Surgery
There are two main reasons health insurance carriers include benefits for meniscus surgery:
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It’s a very common procedure – About 1 million Americans undergo meniscus surgery every year.
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It’s considered medically necessary – Severe meniscus tears nearly always require surgery to heal properly and avoid complications.
Insurers realize that meniscal injuries are relatively frequent, especially among active individuals and athletes They also understand that surgery is the standard treatment for significantly torn menisci that aren’t likely to heal on their own.
For these reasons, the majority of health insurance policies provide coverage for meniscus repair and partial meniscectomy procedures.
Typical Costs of Meniscus Surgery
The cost of meniscus surgery depends on a few factors:
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Surgeon fees – These account for the biggest portion, often $2,000-$4,000.
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Facility/hospital fees – Expect to pay $1,000-$3,000 for the operating room, equipment, nursing care, etc.
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Anesthesia fees – An anesthesiologist’s services generally run $500-$1,500.
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Physical therapy – Post-op rehab averages $100-$150 per session.
Overall, you can expect to pay $5,000-$10,000 for everything related to a simple meniscus surgery. More complex tears or procedures may cost up to $15,000.
Thankfully, with health insurance coverage, your out-of-pocket responsibility is just a fraction of the total fees.
What Insurance Plans Typically Cover Meniscus Surgery
The vast majority of private health insurance plans cover medically necessary meniscus repair and meniscectomy procedures. This includes:
- PPO plans
- HMO plans
- EPO plans
- POS plans
Public and government-sponsored plans like Medicare and Medicaid also provide meniscus surgery benefits. The same is true for most military health insurance policies like Tricare, VA plans, etc.
The Affordable Care Act mandates that all individual major medical and small group health plans cover essential health benefits, including orthopedic care. So meniscus surgery must be included in ACA exchange plans.
Does Insurance Cover Meniscus Surgery for Sports Injuries?
Yes, health insurance will cover meniscus surgery even if the tear happened due to a sports-related injury. The cause of injury doesn’t matter – as long as your doctor determines you have a severe tear requiring surgical repair, it will be covered the same as any other medically necessary meniscus procedure.
With that said, your own health plan pays first. Any supplemental sports accident policy would cover leftover out-of-pocket expenses your health insurance doesn’t cover.
Tips for Getting the Maximum Coverage
While insurance often covers meniscus surgery costs, you’ll typically pay deductibles, copays or coinsurance. Follow these tips to get the most coverage possible:
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Verify surgery is covered and get preauthorization – This ensures no surprises down the road.
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Use in-network providers – Out-of-network care costs much more out-of-pocket.
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Ask about bundled pricing – One bundled fee for the hospital, surgeon, anesthesia, etc. can be cheaper.
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Consider an HSA or FSA – Use pre-tax money to pay any out-of-pocket fees tax-free.
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Appeal claim denials – Mistakes happen, so fight any wrongful non-coverage decisions.
What to Do If Your Insurance Won’t Cover Meniscus Surgery
On rare occasions, an insurer may initially deny coverage for a meniscus procedure. Reasons may include:
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Questioning medical necessity due to minimal symptoms or very small tears.
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Considering the tear a pre-existing condition if symptoms occurred before your plan’s coverage start date.
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Classifying the surgery as investigational or experimental based on improper plan criteria.
If this happens, don’t panic. Have your doctor clearly explain and document why surgery is medically necessary for you. File an appeal providing medical evidence. Contact your state’s department of insurance for help fighting improper denials.
In conclusion, the vast majority of health plans include benefits for medically necessary meniscus surgery. While you’ll have some out-of-pocket costs, insurance will cover the biggest expenses so you can get your knee repaired affordably.
Meniscus Tear Surgery FAQs
The length of meniscus surgery depends on the type of repair that needs to be done. Most surgeries for torn meniscus last between 30 minutes and an hour.
How much is surgery to fix a torn meniscus? Surgery to fix a torn meniscus usually costs between $5,000 and $10,000, but your insurance may cover a lot less.
Treatment Options for Grade 1 and Grade 2 Meniscus Tears
If your doctor checks and sees that your torn meniscus is only Grade 1 or 2, you might not need surgery.
Conservative treatment
Most likely, your doctor will tell you to rest, take painkillers, and put ice on your knee to reduce swelling. While resting your knee, its best to avoid movements that make the pain worse. Elevating your knee while icing it can help reduce swelling and pain. Ice it for 15 minutes at a time every 4-6 hours immediately after the injury. After a couple of days, ice it as needed.
Physical therapy
Your doctor may also suggest physical therapy. This will help to strengthen the muscles around your knee and keep it stable. Most of the time, you can start physical therapy once your knee pain goes away and the swelling goes down.
Physical therapy will usually consist of stretching and strengthening your leg muscles, especially those that support the knee. When you can exercise, your therapist will start you with low-impact exercises. You will likely be able to do more intense exercise once your leg is stronger and your range of motion is better.
Based on how bad your tear is, your physical therapy could last anywhere from four to eight weeks. Your doctor will evaluate your progress to see how long youll need rehabilitation.
Medications
Your doctor may recommend using nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen or naproxen. These can help reduce pain and swelling. Acetaminophen can also help with pain relief.
Your doctor may recommend an injection in the knee with corticosteroids. This anti-inflammatory medication helps reduce swelling and stiffness. Corticosteroids usually begin working in 2-3 days and are usually only given once. This medicine can increase blood sugar levels, so it may not be an option if you have diabetes.
You may need surgery if your doctor thinks you have a Grade 1 or 2 tear but your symptoms are getting worse.
A low-grade tear may not be able to be fixed with these methods. If your doctor finds a Grade 3 tear, you will likely need surgery. The goal of surgery is to remove or repair the meniscus. This should make your knee more stable and lower your risk of getting arthritis later on. First, your doctor will make sure you are healthy enough for surgery. Then, you will probably be put to sleep with general anesthesia.
Your doctor might choose to do any one of the following:
Arthroscopic repair. This is a short procedure that usually takes an hour or less. To get a better look at the joint, your doctor will make small cuts in your knee and put fluid in them to wash away dirt and stop the bleeding. Theyâll insert an arthroscope to see the tear. After, they’ll sew up the tear with small tools that look like darts, which your body will eventually absorb. Because there is little blood supply to this area, only about 10% of tears can be repaired.
Arthroscopic partial meniscectomy. Your doctor will begin with the same process as a repair. They will take out the torn meniscus, though, leaving the healthy part in the joint so your knee can work normally.
Arthroscopic total meniscectomy. Your doctor will take out the whole meniscus if the cartilage is too damaged to keep any part of it. This can often lead to arthritis in the knee over time. If you are a young, healthy person, your doctor may recommend meniscus transplant surgery. Your doctor will get a replacement cadaver meniscus from a tissue bank and place it in your knee.
Knee replacement. It doesn’t happen very often, but if your meniscus is torn and your knee arthritis is very bad, your doctor may suggest a total knee replacement.
Meniscus repair is low-risk. Complications are rare. They may include injury to the skin or nerves, infections, and knee stiffness.
Will a meniscus tear heal itself without surgery?
FAQ
What is the average cost of a meniscus tear surgery?
How bad does a meniscus tear have to be for surgery?
What happens if I don’t repair my torn meniscus?
Is knee surgery covered by insurance?
Can a torn meniscus be repaired without surgery?
Other reasons you may benefit from meniscus surgery is if your torn meniscus is not healing despite non-surgical treatment, or you have another knee injury that also requires surgical repair. Non-surgical treatment of a torn meniscus includes the RICE treatment, along with over-the-counter anti-inflammatories, such as ibuprofen:
Should I get a meniscus surgery?
An orthopaedic surgeon will either repair or remove the damaged portion of your meniscus. A healthcare provider may recommend meniscus surgery if you have a serious (high-grade) torn meniscus or if nonsurgical treatments haven’t managed the symptoms you’re experiencing.
How much does a meniscus tear cost?
How much does the meniscus surgery cost? Meniscus tear surgery usually costs between $5,000 and $10,000, but you may pay much less out of pocket, depending on your insurance coverage. What Is a Meniscus Tear?
What is a meniscus replacement?
A meniscus replacement is surgery to replace a damaged or torn meniscus. The meniscus is a C-shaped piece of cartilage in the knee. You have two of them (menisci) in each knee, one on the inside and one on the outside. These rubbery pieces of cartilage cushion the knee joint and protect the leg bones as they move.