What is an insurance coverage decision?

A health plan is a contract. A medical policy is the plan’s internal document describing what it will fund under that contract, and it is produced by the plan — by its own committee, applying its own criteria, with its own actuarial position in view. It answers one question: will this plan pay for this, for its members, at this price, this year?

That is a legitimate question and payers are entitled to answer it. It is simply not the same question as whether a treatment helps a patient, and nothing in the process is designed to answer that second question.

Who grades the evidence for PRP and orthobiologics?

The bodies that grade medical evidence are professional societies, and they publish under their own names using formal methodology. On orthobiologics the list is not short.

• ESSKA-ICRS and ESSKA-ORBIT — two separate European consensus processes on PRP and injectable orthobiologics for knee osteoarthritis, both published in 2024.
• AAPM&R — a guidance statement on PRP for knee osteoarthritis.
• AAOS — a technology overview of PRP and a clinical practice guideline on nonarthroplasty management of knee osteoarthritis.
• ASIPP — a 119-page evidence-based practice guideline on regenerative therapies in chronic low back pain, appraised with GRADE, carrying 19 recommendations agreed at 100% consensus among 33 participants.
• EFORT — evidence-based guidelines on orthobiologics, 2025.

There is a simple observation to make from that list, and it does most of the work: a practice guideline is a document about practice. Societies convene consensus panels and grade evidence for treatments their members are performing on patients; that is what the format is for and it is the only reason it exists. Six of them have now done so here.

Does insurance cover treatments with weaker evidence?

If coverage tracked evidence, the coverage pattern would track the literature. It does not.

Intra-articular corticosteroid injection for knee osteoarthritis is routinely covered. Jawanda and colleagues, in a 2024 systematic review, found PRP, bone marrow aspirate concentrate and hyaluronic acid all outperformed corticosteroid. The covered option is the one that did worse in the comparison.

That is not a scandal and it is not an accusation of bad faith. Corticosteroid is inexpensive, familiar and long-established, and a plan funding it across millions of members is making a defensible economic choice. It is simply not a choice that carries any information about relative effect — which is the entire point.

Two related traps in the same territory

What we will and will not say about a denial

We will state what the treatment is, what the evidence supports for that specific indication, what it costs the patient to go without, and that the plan declined to fund it. We will not characterize the payer’s motive, allege bad faith, or offer an opinion on the plan contract — those are your questions, not a physician’s.

This practice is not aligned to a side. Its obligation runs to the patient’s health and safety, which is the same reason it is not beholden to any position that would keep it from seeing what is actually there. We do not offer opinions on liability, we do not accept a referral or a review conditioned on reaching a particular conclusion, and we will say plainly when the evidence does not support the claim — whichever party was hoping otherwise.

Frequently asked questions

Does a denial letter mean the treatment is not medically necessary?

It means the plan will not fund it under its own policy. Medical necessity as a clinical judgment is made by the treating physician on the individual patient; the two use the same words for different things.

Can a physician testify about why an insurer denied something?

A physician can describe the clinical indication and the published evidence. The payer’s internal reasoning is not something a treating physician has knowledge of, and claiming otherwise invites a well-earned cross-examination — see expert testimony.

If the evidence is good, why is coverage so consistent across plans?

Plans often rely on shared technology-assessment vendors and on each other, so policies converge. Convergence among payers is not independent replication of a scientific finding.

Does this argument apply beyond orthobiologics?

The logic does. The evidence base does not — it has to be shown for the specific treatment and indication, which is why the evidence page is separated out by body region.

Why isn’t PRP covered by insurance?

Because a coverage decision is a budget decision. A plan’s medical policy is written by its own committee, on its own criteria, with its own actuarial position in view. It answers one question: will this plan pay for this, for its members, at this price, this year? It does not ask whether PRP helps the patient. That question belongs to the professional societies that grade the evidence.

If insurance approves PRP in advance, will it pay for it?

Not necessarily. Prior authorization is not a promise that a claim will be paid. Insurers routinely state that authorization does not guarantee payment, which still turns on eligibility on the date of service, remaining benefits and the plan’s own review after the claim is submitted. A patient told a procedure was “approved” has not been told what it will cost them.

Related reading

• Orthobiologics: PRP and BMAC
• What the evidence actually says
• Orthobiologics, future care and damages
• Expert testimony
• Start here