December 1, 2023

Measured By The Heart

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Insurance Industry’s Denial of PRP Therapy Doesn’t Make Sense

Patients looking to undergo PRP therapy are in the same boat as patients in the 1970s looking to get chiropractic or acupuncture treatments. They have to pay for the procedures out-of-pocket because their health insurance providers will not cover them. Insurance company denial is preventing a lot of people who could benefit from PRP therapy from actually getting it.

A typical PRP procedure can cost a few thousand dollars. Unfortunately, few patients who find relief through PRP therapy get away with just one treatment. Several treatments are often required to see maximum results. That means patients are paying a lot of money out-of-pocket even though they have health insurance policies that can cost anywhere between $7,000 and $20,000 annually.

The maddening thing about it is that if you step back and look at the way insurance companies do business, their denial of PRP therapy doesn’t make a whole lot of sense. It doesn’t make good sense from a business standpoint. It certainly doesn’t make sense from a patient outcome standpoint. But things are so entrenched that is difficult to get any organization within the broader healthcare sector to even consider new ways of doing things.

Regenerative Medicine Is ‘Experimental’

Contact any health insurance company and ask why they don’t cover PRP therapy, and you’re likely to hear that regenerative medicine is experimental medicine. That is the typical response when insurance companies choose to deny something that hasn’t been on the market for decades.

To them, experimental medicine means lost dollars. It makes sense at face value. A person who tries an experimental treatment yet doesn’t see the desired results now has to seek out a more traditional treatment. Why pay for two treatments when the health insurance company can pay for just one?

Again, that looks reasonable on its face. But now let us dig a little deeper. We can use osteoarthritis (OA) of the knee as an example, given that numerous studies have shown PRP therapy to be a valid OA of the knee treatment.

A Predictable Disease

OA of the knee is one of those conditions that is easy to predict. It follows a fairly dependable pattern beginning with mild arthritis pain. As the tissue in the knee slowly degenerates over time, the pain increases. Patients first undergo cortisone shots to relieve inflammation and pain. From there they move to painkillers. Surgery to replace the affected joint is the final step.

Over years of treatment, how much will an insurance company spend? How many tens of thousands of dollars will be spent just on the surgery alone? How much will they spend on physical therapy and post-surgical complications?

Now let’s say you have a patient still in the early stages of OA of the knee – when PRP therapy tends to be most effective. Let’s also assume three PRP treatments are $3,000 each. The insurance company will spend $12,000, less the patient’s deductible – a fraction of what would be spent on a more traditional course of treatment over the patient’s lifetime.

We obviously assume that the PRP therapy works for this patient. No, it doesn’t work for everyone. But it does work for a lot of patients. Those are patients who can cease cortisone injections and pain medication. They are patients who will never need surgery.

Apex Biologix, a Salt Lake City company that supplies a variety of regenerative medicine equipment to doctors and clinics, says that PRP therapy is proving to be a viable option for OA patients. Unfortunately, insurance companies don’t buy it. They would rather spend tens of thousands on traditional treatments that don’t really solve the problem. It makes no sense.