Does Insurance Cover Knee and Hip Replacement? Approval and Costs

Most health insurance does cover a knee or hip replacement. The difficulty is getting there: proving the operation is medically necessary, getting prior authorization, and then paying the deductible, coinsurance and physiotherapy that come with it. This guide explains how approval works, what to do if you are refused, what Medicare and insurers in the UK and Australia actually pay, and when it makes sense to price the operation abroad.

Does insurance cover knee and hip replacement surgery?

Yes, when it is medically necessary. In the US, private plans and Medicare cover total knee and hip replacement for advanced arthritis that has not responded to other treatment, subject to your deductible, coinsurance and network rules. In the UK, the NHS provides joint replacement free at the point of use, and in Canada provincial plans pay for it; the problem in both is the wait, which we cover in our guide to hip and knee waiting times. In Australia, public patients pay nothing, and private patients need the right level of cover.

Treatments that insurers class as experimental or unproven are another matter. Plans may refuse items such as PRP or stem cell injections even when they cover the joint replacement itself, so ask before you pay for any alternative.

Why does insurance require physical therapy before approving a knee replacement?

Because most US insurers want evidence that simpler treatment has been tried first. Plans commonly ask for X-rays showing advanced arthritis, a record of pain and lost function, and a period of conservative care such as physiotherapy, weight management, pain medicine or injections, before they authorise surgery.

Prior authorization is common for joint replacement. In data from four US states presented at the 2024 AAOS annual meeting, 55% of 28,857 primary hip and knee replacements needed prior authorization, approval took 30.2 days on average, and 6% were initially denied, although only 0.4% stayed denied (conference abstract, 2020–23 data). The most common denial reasons were missing documentation and lack of coverage.

So the practical steps are simple: ask your surgeon's office exactly which records your plan wants, keep notes of every physiotherapy session and injection, and confirm the authorization is approved before you book time off work. Ask how many physiotherapy visits your plan covers after surgery too, because many plans cap visits per year and the cap includes any sessions you used before the operation.

Can insurance deny a knee replacement as not medically necessary, and how do you appeal?

Yes, and many denials are overturned when people push back. KFF found that HealthCare.gov insurers denied 19% of in-network claims in 2023; 6% of those denials were for medical necessity and 9% for missing prior authorization or referral. Fewer than 1 in 100 denials were appealed, and insurers upheld 56% of the denials that were (KFF, 2025).

For plans covered by the Affordable Care Act, HealthCare.gov sets out the process: file an internal appeal within 180 days of the denial notice, and for a service you have not had yet the insurer must decide within 30 days, or within 4 business days if the case is urgent. Include your claim number and a letter from your surgeon. If the insurer still says no, you can ask for an external review by an independent third party. Medicare and employer plans have their own appeal routes, so follow the instructions in your denial letter.

How much will you pay with Medicare or private insurance?

Even with cover, expect some cost. Under Original Medicare in 2026, an inpatient stay carries a Part A deductible of USD 1,736 per benefit period, and outpatient surgery and physiotherapy fall under Part B, with a USD 283 deductible and then 20% of the approved amount (medicare.gov). Supplement and Medicare Advantage plans change what you pay, and Medicare Advantage plans often require prior authorization, so check your plan documents.

In Australia, joint replacement is a required category only in Gold hospital cover, and insurers can apply a 12-month waiting period for a condition you had signs of in the six months before joining. For an insured hip replacement, the median out-of-pocket gap for specialists' fees was about AUD 1,000, with a range of AUD 250–4,900, before any hospital excess (cost comparison site citing the government's Medical Costs Finder, 2023–25). Some insurers and surgeons offer no-gap arrangements.

In the UK, private medical insurance rarely helps with a joint that is already painful, because moratorium policies exclude conditions from the five years before cover starts until you have gone two years without symptoms or treatment (Aviva, current).

Will insurance pay for knee or hip surgery out of state or abroad?

Out of state, it depends on your network. Some US plans pay for surgery at an out-of-state centre, especially if your employer has a travel benefit, but out-of-network care usually costs more, so ask for written confirmation first.

Abroad, assume you will pay yourself. As of October 2026, medicare.gov says Medicare usually does not cover care outside the US. The NHS S2 route does not apply to treatment outside Europe. In Ontario, OHIP pays for planned treatment abroad only if an Ontario doctor applies and the ministry approves it in writing before treatment. Basic travel insurance rarely covers planned surgery or its complications. Some private plans reimburse part of planned care abroad, so ask your insurer for written confirmation before you book.

That is why some people simply price the whole operation. In China, patients report total hospital bills before insurance of about CNY 34,650 (≈ USD 5,150) for a hip and CNY 30,000 (≈ USD 4,500) for a knee at public tertiary hospitals (median, Chinese patient reports, 2025–26). Foreign patients pay the full price without Chinese insurance, and international departments charge more, so you would get an individual quote. Our knee replacement cost guide compares this with prices at home and elsewhere.

Plan for the recovery as well as the bill. One NHS orthopaedic hospital recommends waiting 3 months after a hip or knee replacement before journeys longer than 4 hours, and another advises 12 weeks before long-haul flights. Other bodies set shorter limits, so your surgeon decides, but it means a long stay or a careful plan for flying home.