What to do when insurance won't pay for blood-based shots

What to expect from Medicare

An orthobiologic is a shot made from body material, and PRP is the blood-based kind discussed here. The letters PRP are short for platelet-rich plasma: blood is taken from your arm, then spun until platelets collect in the liquid used for the shot given to your joint.

Medicare doesn't generally pay for that shot when it's used for joint or tendon soreness. Its narrow rule covers certain wounds that won't heal, only during a study approved to gather results.

Wounds are mentioned because that's the use covered by the national rule. The rule doesn't extend that payment to an aching joint.

What to ask your plan before care

Call the number on your insurance card before anything is booked. Name the proposed shot, then ask whether the exam or X-ray has its own coverage.

Ask whether the plan needs approval before the visit. Write down the reply, the date, and who took your call.

If the plan won't pay, ask for its decision in writing. Coverage tells you what the plan pays, not whether one kind of care works better.

What to do if the joint doesn't settle

At QC Kinetix, natural pain treatments are non-surgical choices that can use blood taken from your arm and spun during the visit. These regenerative treatments are discussed only after the joint and your health have been checked.

Bring any denial letter and the notes from your plan. A medical provider, the clinician who examines you, can explain the proposed shot and its full cost.

You don't need to decide while you're at the clinic. If the price or payment terms aren't clear, keep asking.

Sources

1. Medicare's national coverage determination states that CMS covers autologous platelet-rich plasma ONLY for patients with chronic non-healing diabetic, pressure and/or venous wounds, and only inside an approved coverage-with-evidence-development clinical study. Every approved study listed under the NCD is a wound-healing study. There is no Medicare national coverage for PRP in osteoarthritis or tendinopathy, which is why these injections are billed to the patient.

   Centers for Medicare & Medicaid Services — Autologous Platelet-rich Plasma (Coverage with Evidence Development). CMS.gov, 2024.

2. FDA's July 2020 final guidance 'Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use' is the document that decides whether a given orthobiologic can be used without a licence: an HCT/P may be regulated solely under section 361 only if it is minimally manipulated AND intended for homologous use, among other criteria; otherwise it is a drug or biological product requiring an approved licence or an active investigational new drug application.

   U.S. Food and Drug Administration — Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use - Guidance for Industry and Food and Drug Administration Staff. FDA Guidance Document, 2020.

3. FDA states verbatim of stem cell products, stromal vascular fraction (adipose-derived cells), umbilical cord blood, Wharton's jelly, amniotic fluid and exosome products: 'None of these products have been approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain.' The only FDA-approved stem cell products in the United States are blood-forming (hematopoietic progenitor) cells derived from umbilical cord blood, approved only for disorders of blood production, and there are currently NO FDA-approved exosome products.

   U.S. Food and Drug Administration — Consumer Alert on Regenerative Medicine Products Including Stem Cells and Exosomes. FDA (Center for Biologics Evaluation and Research), 2020.

4. The BMJ meta-analysis of viscosupplementation pooled 169 trials (21,163 participants) and found clear evidence of small-study effects and publication bias. In the prespecified main analysis of 24 LARGE placebo-controlled trials (8,997 participants) hyaluronic acid reduced pain by SMD -0.08 (95% CI -0.15 to -0.02), equivalent to 2.0 mm on a 100 mm scale - far below the -0.37 minimal important difference - and trial sequential analysis showed there has been CONCLUSIVE evidence of clinical equivalence to placebo since 2009. Fifteen large trials showed a significantly higher risk of serious adverse events (RR 1.49).

   Pereira TV, et al. — Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis.. BMJ, 2022. DOI: 10.1136/bmj-2022-069722.

5. The AAOS third-edition clinical practice guideline on non-arthroplasty management of knee osteoarthritis contains 29 recommendations and explicitly highlights intra-articular corticosteroid, hyaluronic acid AND platelet-rich plasma as the areas where better research is still needed - including osteoarthritis characterisation, subgroup and severity stratification, control for bias, and cost-effectiveness analysis.

   Brophy RH, Fillingham YA. — AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition.. Journal of the American Academy of Orthopaedic Surgeons, 2022. DOI: 10.5435/JAAOS-D-21-01233.

6. In January 2025 federal district court orders resolving a joint FTC and Georgia Attorney General complaint permanently BANNED the co-founders of the Stem Cell Institute of America and several related companies from marketing stem cell therapy, and required payment of $5,155,146 in civil penalties and consumer refunds. In March 2024 the court had granted summary judgment on all counts, finding the defendants created and published false and misleading advertisements about the efficacy of stem cell injections. The affiliated clinic charged up to $5,000 per injection, almost exclusively to elderly and disabled consumers.

   Federal Trade Commission — Stem Cell Institute Co-Founders and Companies Banned from Marketing Stem Cell Treatments and Ordered to Pay More Than $5.1 Million for Refunds and Civil Penalties. FTC Press Release, 2025.