Does Medicare Pay for Platelet-Rich Plasma (PRP)?
Get clear answers on Medicare's coverage of Platelet-Rich Plasma (PRP) therapy. Understand its policies and your potential financial responsibility.
Platelet-Rich Plasma (PRP) therapy has gained attention as a treatment option. This article clarifies Medicare’s stance on PRP therapy and its implications for beneficiaries.
Understanding Platelet-Rich Plasma Therapy
Platelet-Rich Plasma (PRP) therapy uses a patient’s own blood components to support healing. Plasma, the liquid portion of blood, combines with concentrated platelets. These platelets aid clotting and contain growth factors that stimulate tissue regeneration.
PRP is obtained by drawing blood from the patient. This sample is placed in a centrifuge, which spins to separate blood components. This process isolates and concentrates platelets within the plasma. The resulting PRP solution is then injected into the target area, such as an injured joint or tendon, to support natural healing.
Medicare’s General Coverage Framework
Medicare’s coverage decisions require services to be “medically reasonable and necessary” for diagnosis, treatment, or to improve function. This standard means services must be safe, effective, and align with accepted medical practice.
Medicare does not cover services deemed experimental, investigational, or lacking sufficient evidence. The Centers for Medicare & Medicaid Services (CMS) establishes these policies through National Coverage Determinations (NCDs). Medicare Administrative Contractors (MACs) issue Local Coverage Determinations (LCDs), which apply to specific regions and detail coverage not addressed by an NCD.
Medicare’s Position on Platelet-Rich Plasma Therapy
Medicare does not cover Platelet-Rich Plasma (PRP) therapy for most applications. This non-coverage is because Medicare classifies PRP as experimental or investigational due to insufficient evidence for many conditions, particularly musculoskeletal injuries and joint conditions. For conditions like tendinopathies, osteoarthritis, or rotator cuff tears, PRP injections are not covered.
An exception exists for chronic, non-healing diabetic wounds. Under National Coverage Determination (NCD) 270, Medicare covers autologous PRP for these wounds for up to 20 weeks. This coverage requires PRP to be prepared using devices with Food and Drug Administration (FDA) clearance for managing exuding cutaneous wounds, such as diabetic ulcers. For other uses, Medicare’s stance remains non-coverage, reflecting the need for more robust clinical evidence.
Implications of Non-Coverage
When Medicare does not cover Platelet-Rich Plasma therapy, the patient is responsible for the entire cost. Healthcare providers must inform beneficiaries about non-coverage before rendering services. This notification is provided through an Advance Beneficiary Notice of Noncoverage (ABN).
An ABN is a written notice from the provider, indicating Medicare may not pay for a service. It explains reasons for non-coverage and provides an estimated cost. By signing an ABN, the patient acknowledges Medicare may deny payment and agrees to be financially responsible if Medicare does not cover it. Patients should review any ABN and understand their financial obligations before proceeding with services not covered by Medicare.