Yes, Medicare covers Durolane injections under Part B when you have knee osteoarthritis and your medical record shows you’ve already tried other treatments without success. Bioventus, the manufacturer, estimates that about nine out of ten Medicare patients have coverage for the drug as of January 2024.1Bioventus. Durolane Medicare Coverage Coverage is not automatic, though, and Medicare will not pay for Durolane as a first-line treatment or for any joint other than the knee.
Who Qualifies for Coverage
Medicare treats Durolane as a physician-administered injectable under Part B, but the Local Coverage Determinations require every one of the following to be documented in your chart before the claim will be paid.2CMS. LCD L39260 – Hyaluronic Acid Injections for Knee Osteoarthritis
- Symptomatic osteoarthritis of the knee that interferes with daily activities like walking or standing. No other joint and no other diagnosis qualifies.
- X-ray evidence supporting the diagnosis, such as joint space narrowing, bone spurs, or subchondral sclerosis.
- At least three months of failed conservative treatment, including both non-drug therapies (physical therapy, exercise, weight management, bracing, or a cane) and medication (acetaminophen, NSAIDs, or topical capsaicin).
- A failed trial of intra-articular steroid injections, or a documented reason steroids are not appropriate for you.
Medicare will also deny the claim if there is an infection or skin condition at the injection site or if you have a known allergy to hyaluronate products.2CMS. LCD L39260 – Hyaluronic Acid Injections for Knee Osteoarthritis
What You Will Pay
Durolane is billed under HCPCS code J7318 at one unit per milligram. A single injection is 60 mg, so your provider bills 60 units.3CMS. Article A56157 – Billing and Coding: Intraarticular Knee Injections of Hyaluronan The Medicare ASP payment limit for J7318 in the first quarter of 2026 is $6.52 per milligram, which works out to roughly $391 per injection.4OrbDoc. J7318 Drug Pricing
Under Original Medicare, you first pay the $283 Part B deductible for 2026. After that, Medicare pays 80 percent and you pay 20 percent coinsurance.5NCOA. What You Will Pay in Out-of-Pocket Medicare Costs in 2026 On a $391 injection, your 20 percent share works out to about $78 once the deductible is satisfied. If the deductible has not been met yet, you pay the remaining deductible plus 20 percent of what’s left.
A Medigap policy can wipe out that 20 percent. Plans A, B, C, D, F, and G cover 100 percent of Part B coinsurance; Plan K covers 50 percent; Plan L covers 75 percent; and Plan N covers 100 percent with certain office visit copay exceptions.6Medicare.gov. Compare Medigap Plan Benefits With one of the full-coverage plans, you would owe nothing beyond your Medigap premium once the Part B deductible is met.
If You Have Medicare Advantage
Medicare Advantage plans have to cover at least what Original Medicare covers, but they set their own rules on prior authorization, preferred products, and step therapy. Aetna, Anthem, Humana, and UnitedHealthcare all cover Durolane in at least some of their plans.1Bioventus. Durolane Medicare Coverage
What varies is how much friction you’ll run into. Priority Health lists Durolane as a preferred product with no prior authorization for Medicare members.7Priority Health. Medicare PA Criteria Updates for Non-Preferred Hyaluronic Acid Products A Louisiana Blue Medicare Advantage plan treats it as non-preferred and requires X-ray confirmation of at least a Kellgren-Lawrence grade 2 severity score plus a failed trial of Synvisc or Euflexxa first.8Louisiana Blue. MA-015 Intra Articular Hyaluronan Injections Community Health Plan of Washington requires patients to have tried at least two preferred hyaluronic acid products before it will approve Durolane.9Community Health Plan of Washington. Hyaluronic Acid Derivative Clinical Coverage Criteria Call your plan before the appointment and ask whether Durolane is preferred, whether prior authorization is required, and whether any step therapy applies.
What Medicare Will Not Cover
Hyaluronic acid injections in the hip, shoulder, or any joint other than the knee are excluded from Medicare coverage entirely.10AAPC. Sticking Points for Hyaluronic Acid Knee Injection Claims Durolane is not covered for inflammatory conditions such as rheumatoid arthritis, and it cannot be used after a total or partial knee replacement.11CMS. LCD L39529 – Intraarticular Knee Injections of Hyaluronan Doses or injection frequencies above FDA-approved labeling will also be denied. If your doctor uses imaging guidance to place the needle, Medicare pays only for ultrasound or fluoroscopy; CT, MRI, and arthrography are not covered.2CMS. LCD L39260 – Hyaluronic Acid Injections for Knee Osteoarthritis
Repeat Injections
Durolane can provide up to six months of pain relief, and Medicare will cover another injection once that six-month window closes. For the repeat to be paid, you still have to meet all the original eligibility criteria, your symptoms must have returned, and your record must show that the previous injection actually helped with pain and function.2CMS. LCD L39260 – Hyaluronic Acid Injections for Knee Osteoarthritis If the earlier dose did nothing for you, Medicare will not pay for another one.3CMS. Article A56157 – Billing and Coding: Intraarticular Knee Injections of Hyaluronan There’s no annual or lifetime cap beyond the six-month interval and the FDA dosing rules.
Why Claims Get Denied
Even when the clinical picture is right, paperwork sinks claims. The most common denial reasons are an incomplete record of the three-month conservative treatment trial, missing X-ray confirmation, incorrect billing codes, failure to specify which knee was treated, and injections billed more frequently than once every six months without a clear note on symptom recurrence. A missing right-or-left modifier on the claim is enough on its own to trigger a denial.12AAPC. Sticking Points for Hyaluronic Acid Knee Injection Claims If Medicare denies the drug as not medically necessary, it also denies the associated injection procedure code, so the office procedure itself is not reimbursed either.3CMS. Article A56157 – Billing and Coding: Intraarticular Knee Injections of Hyaluronan
If You Cannot Afford Your Share
Bioventus runs a Patient Assistance Program that provides Durolane at no cost to patients with no insurance or inadequate insurance, household income below 300 percent of the federal poverty level, and a valid prescription.13Bioventus. Patient Assistance Program The prescriber certification bars the donated product from being submitted to Medicare, Medicaid, or any other government program, so the program is really for uninsured or underinsured patients rather than a top-up to Medicare.14Bioventus. BV360 Patient Assistance Request Form If your issue is the 20 percent Medicare coinsurance, a Medigap policy will do more for you than the manufacturer program.