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

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.

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.

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.

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.

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