Episode 14: Ask Dr. C-PRP Insurance Coverage and Calf Muscle Tears

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It’s “Ask Dr. C” time again. Today we have a great question about PRP and insurance as well as calf muscle tears and back problems. Let’s dig in.

How is it that PRP has supposedly helped many people, but it’s not covered by insurance?

Great question! PRP is made from the patient’s own concentrated blood platelets. There are dozens of randomized controlled trials that support that PRP is effective in the treatment of orthopedic conditions. So why isn’t it yet covered by insurance?

On the one hand, Tricare (the military insurer)  is starting to offer coverage for PRP to it’s almost 10 million insureds. In addition, our company able to get coverage extended to about 8 million people in the US who work for specific companies. So that’s almost 20 million people who already have coverage.

On the other hand, PRP isn’t yet covered by most private health insurers or Medicare. Despite this, there are more high-level studies supporting the use of PRP than steroid injections or most orthopedic surgeries, so why does insurance cover those things and not PRP? Institutional momentum. Meaning, things that are grandfathered into insurance coverage, even when shown not to work or to be harmful (like steroid shots), tend to be continued to be covered, while new things take forever to clear that hurdle. The good news? I expect limited coverage for PRP with major insurers to happen in the next few years.

BEWARE of Insurance Scams

I can’t answer this question without also discussing the biggest insurance scam out there today which is amnio and umbilical cord product billing. You may see or hear that if you get an amniotic or umbilical cord “stem cell” injection (which doesn’t contain any living stem cells) that it will be covered by Medicare or private insurance. THIS IS A SCAM. The providers that are running this scam are using these products outside of the surgical payment guidelines and as such, just submitting random codes to take advantage of problems in the automated reimbursement systems. Meaning Medicare and insurers are paying these claims in error. Why should you care if it gets paid? Because the clinics doing this will eventually be forced to pay all of this money back (that’s called a clawback). When that happens, you will be the doctor’s piggy bank to fund his defense and reimbursement needs, as all medical clinics have you sign paperwork that says that if your insurer doesn’t pay, you owe that money. So please don’t get scammed by this fraud.

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I recently tore a calf muscle while repetitively going up and down a small ladder while painting. I have a back condition which has affected my knees and I had tried to not do too much stretching the work out several days. Any suggestions on treatment for the calf and the overall low back /knee issues?

I love this question because it shows how connected the back is to what’s happening in your legs. Meaning, if you have a back problem and seemingly innocuous activity suddenly results in a tear in your calf muscle, then it’s more likely than not a problem caused by your back. Meaning that treating the calf without treating the back often will cause a suboptimal result. Both need to be treated at the same time.

Why is this happening? The S1 nerve in your back, which is very commonly involved in patients with back pain, supplies the calf muscle. So when the nerve gets irritated in your back, it also impacts how the calf muscle contracts and the nutrition for the area. Hence the muscle is more likely to get injured.

Early warning signs that you may have an S1 nerve issue in your low back impacting your calf are twitching, jumping, or tightness in the muscle. See my video below for more information:

How can you treat these issues? I have had a tear in my calf muscle caused by my back and we treated my calf with high-dose, ultrasound-guided PRP injections. At the same time, we used platelet lysate injections around my irritated S1 nerves. It took a few months to heal after the injections, but I was fully active during that time. I haven’t had this issue in years now and I never had any surgery either on my calf or on my back.

The upshot? Insurance coverage for PRP is coming. However, in the meantime, don’t fall for insurance scams. In addition, your calf issues may be tied to what’s going on in your back, so treating them will likely require treatment of both the back and the calf at the same time.

If you have questions or comments about this blog post, please email us at [email protected]

NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.

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