Does Medicare cover Platelet-rich plasma (PRP) therapy for knee pain?

Medicare Coverage for Platelet-Rich Plasma Therapy for Knee Pain

Medicare does not cover platelet-rich plasma (PRP) therapy for knee pain as it is strongly recommended against by major clinical guidelines due to inconsistent evidence and lack of standardization.

Guideline Recommendations Against PRP

• The American College of Rheumatology/Arthritis Foundation (ACR/AF) 2019 guidelines strongly recommend against the use of PRP for knee osteoarthritis due to concerns regarding heterogeneity and lack of standardization in available preparations 1
• The American Academy of Orthopaedic Surgeons (AAOS) 2022 guidelines note that while some studies show reduced pain and improved function with PRP, the evidence demonstrates inconsistency with worse treatment responses in patients with severe knee osteoarthritis 1
• Current guidelines emphasize concerns about the lack of standardization in PRP preparation methods, including significant variability in platelet concentration, presence of leukocytes, activation methods, and injection protocols 2

Evidence on PRP Efficacy

• The 2021 RESTORE randomized clinical trial found that intra-articular injection of PRP, compared with saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months 3
• A 2023 systematic review and meta-analysis concluded that while some studies suggest PRP may be effective, the current evidence is of low or very low quality and is based on trials with high risk of bias and significant heterogeneity 4
• A 2015 randomized controlled trial showed that PRP does not provide superior clinical improvement compared to hyaluronic acid for knee cartilage degeneration and osteoarthritis 5

Medicare Coverage Implications

• Medicare typically bases coverage decisions on established clinical guidelines and high-quality evidence demonstrating clinical benefit
• Given the strong recommendations against PRP use from major orthopedic and rheumatology organizations, Medicare does not cover this treatment for knee pain 1, 2
• The ACR/AF guideline specifically states that their recommendation against PRP is not intended to influence insurance coverage decisions, but the strong recommendation against its use has nevertheless informed coverage policies 1

Recommended Alternatives Covered by Medicare

• First-line treatments that are typically covered include:
  • Physical therapy and structured exercise programs 2
  • Weight management interventions for overweight patients 1
  • Oral and topical NSAIDs where appropriate 1, 2
• For patients with inadequate response to first-line treatments, intra-articular corticosteroid injections are recommended and typically covered by Medicare, with benefits lasting approximately 3 months 1, 2

Common Pitfalls and Caveats

• Some providers may suggest that PRP is covered by Medicare in certain circumstances, but this is generally not accurate for knee osteoarthritis treatment 1, 2
• Patients should be aware that PRP is typically an out-of-pocket expense and costs can vary significantly between providers 2
• The lack of standardization in PRP preparation means that even if a patient chooses to pay out-of-pocket, the treatment they receive may differ substantially from what was used in clinical studies 1, 2
• Patients should be informed that current high-quality evidence does not support the use of PRP for knee osteoarthritis despite some positive results in lower-quality studies 3, 4