insurance not cover regenerative medicine

Unpacking the Reasons Behind Insurance Denials for Stem Cell Therapy

There are several opinions on why insurances are not covering regenerative medicine (i.e. “stem cells”) treatments. The first one you may hear is that because it is not FDA approved and considered “experimental”. Typically, the first to cover these types of new treatments would be Medicare. Once they approve it, then the other insurance companies follow suit. This is a safe approach because Medicare is very conservative and does a very good job studying a product before covering it.

They like to see the long term effects of the product as well, and they like to be in control of the studies for the product. Medicare typically does not accept third party data for making these types of decisions. So the first step that would need to be taken is for Medicare to start some studies to determine the effectiveness of regenerative medicine products like stem cells, wharton’s jelly allografts, amniotic tissue allografts, platelet rich plasma, etc. These take time, and then the data analysis that follows would also take time. We are not aware of any studies currently being done by Medicare, so it may still be a while before they are covered.

For those of you that like conspiracy theories, here is one that I have also heard about why insurances are not covering regenerative medicine treatments. This “theory” says that the medical industry, specifically pharmaceutical and surgeons are against these products being covered by insurance, and since they have pretty strong lobby organizations, they are holding up the approval from insurance companies.

The reason being that the pharmaceutical industry still has not figured out how they can make money on these types of products, so they are lobbying against it. Surgeons make a lot of money from performing a surgery. For example, a knee replacement surgery can cost anywhere from $50,000 to $70,000. The surgeon makes a lot of money from these types of surgeries.

If they had to give an injection that costs around 10% of that amount, they would be seeing a significant reduction in income, so they have their lobbyists also stopping their approval. How true this is, I don’t know, but that is a theory that I have heard.

Realistically, it is just a matter of time before regenerative medicine is covered by insurances. These products are growing in popularity, and the FDA and other government organizations are looking at them much more closely than they were 5-10 years ago. That is a good sign, and hopefully some day they will be covered. In the mean time, we can all take solace in knowing that due to all this increased attention, the products that are on the market are getting better and safer.

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