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

Abstract

TRICARE is the primary health insurer for US military personnel, military retirees, and their families. Between October 1, 2019 (FY2020) through September 30, 2024 (FY2024), TRICARE authorized private sector reimbursement of outpatient platelet-rich plasma (PRP) injections for knee osteoarthritis and lateral epicondylitis without the need for prior authorization, despite minimal evidence of efficacy for these conditions. We sought to describe utilization and reimbursement patterns for outpatient PRP injections covered under the TRICARE Provisional Coverage Program to illustrate potential usage patterns where PRP was generally covered without regard for scientific evidence of effectiveness. (1) What was the total number of, reimbursement for, and temporal variation of PRP injections reimbursed to nonmilitary providers during the TRICARE Provisional Coverage Program? (2) What proportion of reimbursed PRP injections met authorized use criteria under the Provisional Coverage Program? (3) What was the geographic variation in utilization and cost of PRP injections under the Provisional Coverage Program? The Military Data Repository (MDR) was queried for all paid claims by TRICARE for Current Procedural Terminology code 0232T (injection of platelet-rich plasma) administered at nonmilitary clinics between October 1, 2019, and September 30, 2024 (FY 2020 through 2024); there were 13,277 such claims. To the best of our knowledge, this is the only centralized location containing data on all such claims. Claims were excluded when the injections were performed in an inpatient setting, performed in conjunction with a surgical procedure, administered in an ambulatory surgery center, or the reason for the injection could not be ascertained from the listed ICD-10 diagnosis codes; after applying those exclusions, 95% (12,613) were further considered, encompassing 13,386 injections. Claims were considered to have "met criteria" if filed with an associated ICD-10 code for knee osteoarthritis or lateral epicondylitis. Claims were considered to have "potentially met criteria" if administered for any diagnosis of the knee or elbow. All other claims were categorized as "not meeting criteria." Mean reimbursement (amount paid by TRICARE to providers) was calculated for the total cohort and for each US state individually. The number of injections increased annually, from 657 injections in FY2020 to 4140 injections in FY2024. The mean reimbursement increased 266% over the study period from FY2020 (USD 667 per injection) to FY2024 (USD 1764 per injection). Most injections (92% [12,253 of 13,386]) definitively or potentially met TRICARE criteria for reimbursement. One clinic received more than USD 7 million in reimbursement, accounting for nearly one-third of the money reimbursed nationally. During the 5 years that outpatient PRP treatment was covered by TRICARE without preauthorization, utilization showed substantial year-on-year increases, with associated increases in reimbursement to providers. The value of these treatments is questionable given the weak evidence base for its use. The program allowed for one outlier clinic to receive millions of dollars while still technically adhering to requirements. Policymakers should consider both the efficacy of treatment and the potential for exploitation when considering coverage of newer treatments and institute administrative controls to protect against outlier behaviors. Level IV, therapeutic study.