Does Medicare Pay for Orthobiologics? Coverage Explained

Medicare and Orthobiologics Coverage

As more patients look for alternatives to surgery or long-term pain medications, interest in biologic treatments has grown—especially among older adults living with arthritis and joint pain. This has led to a common question: does Medicare pay for orthobiologics?

The short answer is: not usually. While some biologic injections like hyaluronic acid may be covered in very specific situations, most other orthobiologic therapies such as platelet-rich plasma (PRP) and stem cell–based options are not.

This guide explains what counts as orthobiologics, what Medicare currently covers, typical costs if you pay out of pocket, and the most common misconceptions about insurance coverage.

📌 For a broader look at how these treatments are used, see: Practical Uses of Orthobiologics in Modern Medicine.

What Are Orthobiologics Under Medicare’s Lens?

Orthobiologics are therapies that use biological substances—often taken from a patient’s own body—to support healing in joints, bones, tendons, and ligaments. Common examples include:

• Platelet-Rich Plasma (PRP): Uses concentrated platelets from blood to deliver growth factors into injured tissue.
  

• Platelet-Rich Fibrin (PRF): Similar to PRP but with a slower release of growth factors.
  

• Hyaluronic Acid (HA) injections: Lab-prepared gel-like fluid that lubricates joints, especially knees.
  

• Bone Marrow Aspirate Concentrate (BMAC): Stem cell–rich marrow aspirate injected into injured joints or tendons.
  

These treatments are often discussed together, but from Medicare’s perspective they are not all viewed equally.

Many patients assume that if a treatment is available in a clinic, it must be covered. That’s not the case—Medicare has strict requirements, and this confusion is a major reason why patients are surprised by out-of-pocket bills.

Medicare’s Current Coverage Rules

Does Medicare cover orthobiologic injections? It depends entirely on the type:

• PRP (Platelet-Rich Plasma): Not covered by Medicare for musculoskeletal or orthopedic conditions. The only current exception is for chronic non-healing wounds (and even that requires strict documentation and prior approval).
  

• PRF (Platelet-Rich Fibrin): Not covered. Considered experimental.
  

• BMAC / stem cell–based therapies: Not covered. Classified as investigational and not approved for general orthopedic use.
  

• Hyaluronic Acid (HA) injections: Often covered for knee osteoarthritis if certain criteria are met.
  

So if you’re asking what biologic is covered by Medicare, the answer right now is hyaluronic acid—and only for specific knee arthritis cases. All other common orthobiologics are considered out-of-pocket treatments.

Why Most Orthobiologics Aren’t Covered Yet

It’s not that Medicare is against innovation. It’s that coverage is based on strict evidence requirements:

• Lack of standardized protocols: Different clinics prepare PRP and stem cell injections in different ways, so outcomes aren’t consistent.
  

• Insufficient large-scale trials: Most studies are small and show mixed results.
  

• Uncertain long-term benefit: Medicare typically covers treatments with strong evidence of durable improvement.
  

This is why Medicare considers PRP, PRF, and stem cell–based therapies “investigational” rather than standard care.

A key misconception is:

“If my doctor offers it, Medicare must cover it.”
This is false. Doctors are free to offer cash-pay treatments, but Medicare is not obligated to reimburse them.

When HA Injections May Be Covered

Hyaluronic acid is the one orthobiologic therapy that may be covered by Medicare in certain cases. This typically includes:

• A confirmed diagnosis of knee osteoarthritis
  

• Use of an FDA-cleared HA product
  

• Documented failure of conservative care (like physical therapy or NSAIDs)
  

• The injection is performed by an eligible provider
  

• A prior authorization request is approved if required by your plan
  

If these criteria are met, Medicare Part B usually covers 80% of the cost of the HA injection, and the patient is responsible for the remaining 20% (or less if they have supplemental coverage).

📌 For more about what HA is and how it works, see: Hyaluronic Acid as an Orthobiologic Option.

How to Check If Medicare Will Cover Your Treatment

Because rules can vary, the safest approach is to confirm before you get treated. Here’s how:

1. Ask your provider’s billing staff to submit a coverage request or prior authorization.
   

2. Call 1-800-MEDICARE and ask if the specific CPT code for your injection is covered.
   

3. Use the Medicare Coverage Database (MCD) online to search for your therapy.
   

4. Request a written cost estimate from your clinic before you book the appointment.
   

If your provider cannot give you a billing code or cost estimate, that usually means the treatment is offered as self-pay only.

📌 If you’re unsure what’s included in a treatment, read: Orthobiologic Treatment Explained.

What It Costs If Not Covered

If Medicare does not cover your chosen orthobiologic therapy, you should expect to pay the full cost yourself. Here are typical cash-pay price ranges:

• PRP injections: $500 to $2,000 per session
  

• BMAC / stem cell–based injections: $3,000 to $7,000+ depending on site and preparation
  

• HA injections: $300 to $1,000 per series (if not covered)
  

Most clinics require payment upfront and do not offer reimbursement paperwork, because these are not recognized as billable services by Medicare.

Common Misconceptions About Coverage

Patients and caregivers often have understandable—but incorrect—assumptions about Medicare coverage. Let’s clear them up:

❌ “If my doctor offers it, Medicare must cover it.”
 Doctors can offer cash-pay services even if they aren’t covered.

❌ “If it uses my own blood, it’s automatically covered.”
 PRP and PRF use your own blood, but they are not covered for orthopedic use.

❌ “PRP and HA are basically the same.”
 HA is an FDA-cleared product sometimes covered for arthritis. PRP is prepared individually from blood and not covered.

❌ “Medicare will reimburse me if I submit receipts later.”
If the service is non-covered, you cannot get retroactive reimbursement.

Clarifying these points early can prevent surprise bills and frustration.

Future Outlook on Orthobiologics and Medicare

Many clinicians are hopeful that PRP and other orthobiologics may eventually become covered as research expands. Several large trials are underway to study PRP in knee osteoarthritis and rotator cuff injuries.

If future data proves that these therapies are safe, cost-effective, and consistently beneficial, Medicare could reconsider coverage. For now, though, they remain classified as investigational.

Conclusion

So, does Medicare pay for orthobiologics?

• Mostly no—PRP, PRF, and stem cell–based therapies are not covered.
  

• Sometimes yes—hyaluronic acid injections may be covered for knee osteoarthritis if strict conditions are met.
  

If you or a loved one are considering orthobiologic therapy, it’s essential to ask about cost and insurance before starting treatment. This avoids unexpected expenses and helps you make informed choices about your care plan.

About Me

I’m Oscar Tellez, I’ve spent the past 10 years working in regenerative medicine. My focus is on advancing safe, evidence-based applications of PRP, fat, bone marrow, birth tissues such as Wharton’s Jelly, exosomes, and cell factors.I share insights designed to help clinicians responsibly integrate regenerative care into their practice while staying compliant with FDA, FTC, and DEA guidelines.

You can connect with me directly on [Website], [LinkedIn] and [Facebook].

DISCLAIMER:
This content is for educational purposes only and is not intended as medical or legal advice. Regenerative medicine products and therapies are subject to FDA, FTC, and DEA regulations. Clinicians should verify compliance and consult with qualified professionals before offering these treatments.