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Stem Cell Therapy and PRP are new and cutting-edge treatments for joint pain. Both have been around for a number of years, but are not universally recommended by orthopedists.
A common question we’re asked as providers of regenerative medicine is whether or not insurance will cover the costs of stem cell and PRP injections.
The short answer to the question is likely no.
Insurance providers consider these orthobiologic treatments as “experimental” or “speculative. Most health insurance providers would prefer an alternative treatment. They focus on medicines and procedures that have been well studied and undergone clinical trials.
However, there are cases where you may be offered limited coverage for PRP. In this article, we go over:
- Why regenerative medicine injections are often not covered by insurance
- Which insurance companies cover PRP
- Alternative ways to get these treatments
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- Are Suffering From Pain and Mobility Issues
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Why Don’t Most Insurance Companies Cover PRP or Stem Cell Injections?
The main reason insurance doesn’t cover PRP injections or stem cell therapies is because of the evidence base. Most traditional treatments have had years of research studies to back their use. However, while PRP and stem cells are different, they are both new techniques.
As there aren’t many large studies on these treatments, insurance companies say they are “experimental”. Some insurance providers also state that the two therapies are “unproven” and “investigational”.
Instead, insurance companies will recommend traditional treatments. These have already gone through scientific trials and research. This means insurance companies are more likely to cover them.
It’s important to note that these specific therapies are still an emerging area in the medical world. Sure, there’s a lot of research that has gone into them. However, at this point, insurance providers won’t view them as a conventional option as more researched options are available.
So How Do I get PRP or Stem Cell Injections?
You do have options, even though insurance doesn’t often cover these treatments.
It’s best to begin by talking with Dr. Mehta about the best treatment option for your situation. Dr. Mehta offers concierge care. What this means is you don’t have to worry about digging into your deductible. All care is personalized to you, and you have a greater choice of treatment.
There are also no kind of insurance documents or paperwork to fill out and worry about. That’s because the concierge care gives you access to an out-of-pocket service for PRP injections and stem cell therapy.
The good news is that this type of approach makes everything easier and faster. Since there is no insurance documentation to focus on, you can get the therapy done without delays.
Since this is an out-of-pocket procedure, it’s a good idea to talk to Dr. Mehta about the treatment options. She can help you understand what these treatments can do for you, giving guidance on the pricing.
You’ll also be able to get an idea of whether you might need to go for follow-up sessions. This makes it easier to determine how the treatments can fit into your budget.
What Insurance Companies Cover PRP Therapy?
Most insurance companies will consider PRP therapy experimental and not provide coverage. However, there are some exceptions.
Right now, Tricare is the only provider that offers limited coverage for PRP injections.
Next, we’ll take a closer look at what the major insurance companies say about the treatment.
Tricare
Tricare is one of the major health insurance providers in the U.S., providing care for active duty service members. It is also the only one to offer some coverage for PRP.
The provisional coverage means you’ll only be covered for a certain period of time. This is according to the company’s official policies and can extend to a period of up to five years.
However, it’s important to note that there are limitations to when PRP will be covered as part of your insurance plan. This includes people with:
- Chronic mild to moderate osteoarthritis in the knee.
- Lateral epicondylitis (under certain conditions)
Medicare
Medicare does not offer coverage for PRP in patients with osteoarthritis or other orthopedic conditions.
However, there is one specific area where coverage may be granted. This is in cases where you’re a diabetic and you have certain wounds that won’t heal.
There are strict requirements for this kind of case. For example, Medicare specifically states that you have to be enrolled in a clinical trial, and it must meet certain conditions.
Blue Cross Blue Shield
In most cases, if you’re covered by Blue Cross Blue Shield, you don’t have any coverage for PRP injections. They tend to classify these treatments as investigational, so they are on the non-cover list.
Blue Cross Blue Shield classifies PRP for orthopedic uses as experimental/investigational, citing limited and inconsistent evidence. This is the main reason why they refuse coverage.
Cigna
Cigna Healthcare has provided updated information on their policies regarding PRP therapy. The insurance company currently provides no coverage for the use of platelet-rich plasma injections in any case. This is regardless of the condition you have.
Cigna classifies these therapies as unproven and experimental.
Aetna
Similar to Cigna, Aetna has also offered a statement that defines PRP treatments as unproven and experimental.
The healthcare insurance provider claims that there is not enough evidence available. They won’t cover this until they can prove the effectiveness of PRP.
Thus, they also do not offer any kind of coverage for the therapy.
United Healthcare
If you have United Healthcare, then you’re also not going to be covered for PRP injections.
The company clearly states that no form of platelet-rich plasma therapy will be covered. This is regardless of the condition that needs to be treated. This includes the use of PRP for musculoskeletal injuries, joint diseases, and wounds that won’t heal.
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Which Insurance Covers Stem Cell Injections?
While there are some limited coverage options available for PRP, the same cannot be said for stem cell injections. No major insurance companies cover stem cell injections for orthopedic conditions.
There are cases where stem cell transplantation is covered. If you fall under Tricare and you are elite military personnel, then there’s a chance that they will cover transplantation.
However – don’t get confused by this. Stem cell transplantation is not the same as stem cell treatment for joint conditions
Transplant of stem cells is usually only considered an appropriate choice in cases of blood cancer. Sometimes, this strategy might be used when you undergo chemotherapy as well.
According to Tricare, the only two options that might be covered in some instances include bone marrow transplants. There are strict requirements, and it will only be covered if the doctors are able to prove these procedures will be both safe and effective.
The company also states that if they cover the procedure, non-medical expenses will be your responsibility.
If you want stem cell injections for an orthopedic condition, this will not be covered by insurance. Instead, you’re best seeking a concierge medicine provider such as Dr. Mehta for your treatment.
When Will Insurance Companies Cover PRP & Stem Cell Therapy
Stem cells were first discovered in 1888, but the first transplantation procedure was only done in 1958. This was on five nuclear workers injured in a “criticality accident“. All of the workers survived. Since then, a lot of progress has been made. Researchers have begun to focus on understanding the use of stem cells as treatment.
PRP injections have also been closely studied. Scientists are interested in the potential that the growth factors in the platelets offer. Theoretically, this helps to boost the body’s natural healing capabilities.
While researchers have worked with stem cells and PRP for a long time, they are still considered emerging treatments. Some studies focus on the safety and effectiveness of the treatments in humans. However, most of the available evidence is limited to research performed on animals.
Some studies looked at the impact of both PRP and stem cell therapies on human subjects. However, the data that’s available isn’t enough for most insurance companies to consider these treatments viable options.
This means more research is needed before insurance companies cover PRP and stem cells. At the current rate, you can see that PRP has better coverage than stem cell injections, even though still very limited. It’s therefore likely that platelet-rich plasma therapies become covered before stem cell treatments.
For example, these companies want to see double-blind clinical trials and bigger pools of participants. Right now, these are limitations and challenges that the treatment options face. Insurance companies, the FDA, and other medical authorities prefer data from large studies.
When there is only a small number of participants in a study, it can’t provide a strong reassurance of effectiveness.
If we reach a point where large studies show safety and effectiveness, we will see a change. In this case, insurance companies will be more open to the idea of covering stem cell therapies and PRP injections.
