How Is Platelet-rich Plasma Utilized by Outpatient Providers When Covered by Insurance Without Need for...

Area of Science:

• Orthopedics
• Regenerative Medicine
• Health Services Research

Background:

• TRICARE, the health insurer for US military personnel and families, covered outpatient platelet-rich plasma (PRP) injections for knee osteoarthritis and lateral epicondylitis without prior authorization from FY2020 to FY2024.
• This coverage was provided despite minimal evidence supporting the efficacy of PRP for these conditions.

Purpose of the Study:

• To analyze the utilization, reimbursement, and geographic variation of PRP injections covered under the TRICARE Provisional Coverage Program.
• To determine the proportion of PRP injections that met TRICARE's authorized use criteria.

Main Methods:

• The Military Data Repository was queried for TRICARE claims of Current Procedural Terminology code 0232T (PRP injection) administered at nonmilitary clinics between October 1, 2019, and September 30, 2024.
• Claims were analyzed for adherence to TRICARE criteria based on ICD-10 diagnosis codes for knee osteoarthritis or lateral epicondylitis.
• Mean reimbursement was calculated, and geographic variations were assessed.

Main Results:

• Injections increased annually from 657 in FY2020 to 4140 in FY2024, with mean reimbursement rising 266% from $667 to $1764 per injection.
• 92% of injections met or potentially met TRICARE criteria.
• One clinic received over $7 million, representing nearly one-third of national reimbursement.

Conclusions:

• Outpatient PRP coverage by TRICARE without preauthorization led to significant increases in utilization and provider reimbursement.
• The clinical value of these treatments remains questionable due to a weak evidence base.
• Policymakers should evaluate treatment efficacy and implement controls to prevent exploitation by outlier providers.