Platelet-rich plasma (PRP) injections are a regenerative therapy derived from a patient’s own blood, which is processed to create a concentrated solution of platelets and growth factors. This plasma concentrate is then injected into an injured or damaged area to stimulate the natural healing process and potentially reduce pain. PRP has been widely applied for various musculoskeletal conditions, including chronic tendon injuries, ligament damage, and osteoarthritis. Medicare coverage for this procedure is highly restricted and depends entirely on the specific medical condition being treated. Medicare’s policy is to generally not cover the injections for the majority of common applications.
The General Rule of Non-Coverage
Medicare, managed by the Centers for Medicare & Medicaid Services (CMS), operates under the principle that a medical service must be deemed “reasonable and necessary” for the diagnosis or treatment of an illness to qualify for coverage. For most conditions commonly treated with PRP, such as chronic tendinopathy, “tennis elbow,” rotator cuff tears, or knee osteoarthritis, Medicare does not provide reimbursement. This broad denial stems from a determination that there is insufficient high-quality, long-term clinical evidence demonstrating the effectiveness of PRP across these specific musculoskeletal applications.
CMS frequently classifies PRP procedures for these common orthopedic issues as “investigational” or “experimental.” Treatments that fall into this category are typically excluded from coverage, regardless of a physician’s recommendation. The lack of standardized preparation protocols for PRP, where concentration levels and components vary, also contributes to the difficulty in proving consistent clinical benefit that meets Medicare’s evidentiary standards. Therefore, patients receiving PRP for most joint and soft tissue injuries should expect to pay the full cost out-of-pocket, which can range from $500 to $2,500 per injection, and multiple sessions are often required.
This non-coverage policy is formalized through National Coverage Determinations (NCDs) and the lack of positive coverage decisions for these widespread conditions. CMS maintains a cautious approach, requiring substantial evidence from randomized controlled trials to establish long-term efficacy and justify the use of taxpayer funds. Until a sufficient body of evidence supports PRP’s consistent superiority over standard treatments for conditions like osteoarthritis, Medicare will maintain its position of non-coverage for these indications.
Specific Situations Where PRP Might Be Covered
Despite the general exclusion, Medicare does cover autologous PRP therapy under a specific National Coverage Determination (NCD) for the treatment of chronic non-healing diabetic wounds. This applies to ulcers on the lower extremities that have failed to heal after 30 days of standard care. Coverage for this specific wound care application is limited to a treatment duration of 20 weeks and requires the PRP to be prepared using devices and techniques approved by the Food and Drug Administration (FDA). This coverage was established after a thorough review found sufficient evidence of improved outcomes compared to conventional treatments for this severe complication of diabetes.
Coverage can occasionally be secured if the PRP injection is administered as part of an approved clinical research study. Medicare supports certain costs associated with participation in clinical trials designed to collect necessary evidence on new or non-covered procedures. This mechanism, known as Coverage with Evidence Development (CED), allows beneficiaries to access the therapy while contributing to the scientific data needed to determine future coverage policy, provided the trial meets specific CMS-approved criteria.
Local Coverage Determinations (LCDs)
Another potential, though less common, avenue for coverage is through Local Coverage Determinations (LCDs). These are policies set by regional Medicare Administrative Contractors (MACs). A MAC may issue an LCD that allows coverage for a very specific, limited diagnosis within its geographic jurisdiction. This sometimes includes non-diabetic chronic wounds or non-union fractures not addressed by the NCD. These LCDs are rare for musculoskeletal conditions, and their coverage criteria are highly specific and geographically restricted, meaning coverage varies by region.
Understanding Patient Financial Responsibility
When a healthcare provider anticipates that Medicare will deny coverage for a PRP injection because it is considered experimental or not medically necessary, they are required to issue an Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131. This notice informs the Medicare beneficiary before the service is rendered that Medicare is likely to deny the claim. The ABN clearly states the reason for the expected denial and provides an estimate of the patient’s total out-of-pocket cost.
By signing the ABN, the patient acknowledges and accepts full financial responsibility for the procedure if Medicare denies the claim. If the claim is submitted to Medicare and subsequently denied, the patient is responsible for 100% of the cost, as the therapy does not fall under the standard Part B deductible and coinsurance structure for covered services. If the patient chooses to proceed without signing the ABN, the provider may elect not to perform the service, or the patient may be held financially harmless if Medicare denies the claim, if the provider failed to give proper notice.
A patient retains the right to appeal a denial even after signing an ABN. However, appeals for treatments denied based on their “investigational” status often face significant challenges. Overturning a denial based on a national policy determination regarding a lack of scientific evidence is difficult without unique medical circumstances. Beneficiaries should consider the ABN a warning that the entire cost of the PRP injection will be their personal financial obligation.