Does Medicare Cover This Procedure? Coverage and Payment Lookup

For a given diagnosis, what Medicare’s own coverage records say about each procedure — which diagnoses they list, and Medicare’s professional payment baseline. Coverage records, not treatment advice.

Example: Knee injection options for osteoarthritis (M17)

Scenario: Compare three knee injection procedures for diagnosis M17 (knee osteoarthritis): joint aspiration/injection (20610), major joint injection with ultrasound (20611), and platelet-rich plasma injection (0232T).

What you see:

  • 20610 — Listed as covered for M17 diagnoses in Medicare coverage articles. Professional payment baseline: $69.15 (non-facility), $39.95 (facility) per the CMS Physician Fee Schedule.
  • 20611 — Listed as covered for M17 diagnoses. Professional payment baseline: $104.73 (non-facility), $50.35 (facility) per the CMS Physician Fee Schedule.
  • 0232T — Coverage is governed by the local Medicare contractor's policy rather than listed for M17. No national professional payment rate is published for this Category III CPT code, which is reported as missing, never as non-coverage.

Critical limitation: This tool shows what Medicare's coverage records and payment schedule say — it is not a treatment recommendation and does not compare clinical effectiveness. A missing national rate is not evidence of non-coverage. Coverage depends on diagnosis, documentation, and the applicable Medicare contractor's local policy. This is not a guarantee of payment and does not predict what commercial insurance covers or what you would personally pay.

This shows what Medicare’s coverage records say — not which option is better.
Four different kinds of fact appear below and they are not interchangeable:
  • Coverage evidence — what a Medicare Local Coverage Article lists for this code
  • Payment baseline — the CMS Physician Fee Schedule professional amount — the clinician component only, not the whole visit
  • Diagnosis applicability — the ICD-10 diagnoses those articles name as covered or non-covered
  • Unknown — contractor-specific policy, commercial insurance, and anything patient-specific

Diagnosis M17 (knee osteoarthritis — the default comparison)

Injecting a substance into a major joint to relieve pain or swelling 20610
Listed as covered for this diagnosis
A Medicare coverage article lists this diagnosis among those supporting medical necessity for this procedure (9 matching code(s)). Listing is not a guarantee of payment — the claim still has to meet the article's other conditions.
Medicare professional payment baseline: $68.81 (non-facility PFS, CMS PFS 2026 Oct (RVU26D); facility $39.75)
the clinician’s professional fee only. It is not the price of the visit, and it does not include a facility fee, the drug or device injected, imaging, or anything you would be billed separately.
Diagnoses listed as covered matching M17:
M17.0M17.11M17.12M17.2M17.31M17.32M17.4M17.5M17.9
Medicare coverage articles (4):
  • Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis (59030, revised 2026-01-27)
  • Billing and Coding: Intraarticular Knee Injections of Hyaluronan (56157, revised 2026-01-20)
  • Billing and Coding: Hyaluronans Intra-articular Injections of (52420, revised 2025-12-22)
  • Billing and Coding: Use of Laterality Modifiers (56869, revised 2024-12-17)
Injection into a major joint or bursa using ultrasound guidance 20611
Listed as covered for this diagnosis
A Medicare coverage article lists this diagnosis among those supporting medical necessity for this procedure (9 matching code(s)). Listing is not a guarantee of payment — the claim still has to meet the article's other conditions.
Medicare professional payment baseline: $104.21 (non-facility PFS, CMS PFS 2026 Oct (RVU26D); facility $50.10)
the clinician’s professional fee only. It is not the price of the visit, and it does not include a facility fee, the drug or device injected, imaging, or anything you would be billed separately.
Diagnoses listed as covered matching M17:
M17.0M17.11M17.12M17.2M17.31M17.32M17.4M17.5M17.9
Medicare coverage articles (4):
  • Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis (59030, revised 2026-01-27)
  • Billing and Coding: Intraarticular Knee Injections of Hyaluronan (56157, revised 2026-01-20)
  • Billing and Coding: Hyaluronans Intra-articular Injections of (52420, revised 2025-12-22)
  • Billing and Coding: Use of Laterality Modifiers (56869, revised 2024-12-17)
Injection of platelet rich plasma for various non-wound conditions 0232T
Governed by local contractor policy — we cannot see the diagnosis list
6 active Medicare coverage article(s) govern this code, but our extract holds no diagnosis lists from them. Coverage is set by your Medicare Administrative Contractor and we cannot read it here. This is NOT a finding that the procedure is non-covered.
Medicare professional payment baseline: none published.
No national Physician Fee Schedule amount is published for this code. Category III and carrier-priced codes are priced locally by the Medicare contractor. A missing national rate is NOT evidence that the procedure is non-covered.
Medicare coverage articles (6):
  • Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (58788, revised 2025-09-04)
  • Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (58737, revised 2023-11-15)
  • Billing and Coding: Platelet Rich Plasma (58810, revised 2023-07-14)
  • Billing and Coding: Platelet Rich Plasma (58808, revised 2023-07-14)
  • Billing and Coding: Platelet Rich Plasma (58282, revised 2023-06-19)
  • Billing and Coding: Platelet Rich Plasma (58609, revised 2021-11-19)

What to verify

  • Check your own Medicare contractor’s policy →
    Coverage for these procedures is set locally. The CMS Medicare Coverage Database is the authoritative place to read the article that applies to you.
  • Questions to put to the clinic before the appointment
    Ask which code they will bill, whether they participate with Medicare, whether a facility fee applies, and what the drug or device will be billed as — those determine the bill far more than the professional fee does.
Before you rely on this
  • This shows what Medicare coverage records SAY. It is not medical advice, it does not compare how well these options work, and it does not recommend one over another — that is a conversation with your clinician.
  • Medicare payment amounts here are the PHYSICIAN FEE SCHEDULE professional component: the clinician’s fee. They are not what a visit costs. A facility fee, the injected drug or device, imaging and anything billed separately are all excluded.
  • Coverage for these procedures is largely set by LOCAL Medicare Administrative Contractors, so it varies by region. Where several active articles exist for one code, that variation is why. Your own contractor’s policy governs your claim.
  • A missing national payment rate does not mean a procedure is not covered. Category III and carrier-priced codes are priced locally rather than nationally.
  • Being listed as covered for a diagnosis is not a guarantee of payment. The article’s other conditions — documentation, frequency limits, prior therapy — still apply.
  • Nothing here describes commercial insurance, Medicare Advantage plan rules, or what you personally would pay.
  • Coverage articles shown carry their own revision dates; the most recent here is 2026-01-27. Medicare contractors revise these, so check the article itself before relying on it.

Medicare coverage records from the CMS Medicare Coverage Database and the CMS Physician Fee Schedule. Not medical advice, not a treatment recommendation, and not a statement about commercial insurance or what you would personally pay.

Data: CMS Medicare Coverage Database Local Coverage Articles; CMS Physician Fee Schedule — Medicare coverage articles, most recent revision 2026-01-27 · source

Machine access — this tool is available as structured data for AI assistants and agents:
GET https://medicalclaim.ai/tools/procedure-coverage/data.json?diagnosis=…&codes=…
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