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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that: 
 
Primary Treatment for Osteoarthritis: 
 
Osteoarthritis (OA) is a common disease involving joint damage, inadequate healing response, and progressive 
deterioration of the joint architecture. Presently, intra-articular injections of CS or viscosupplementation with 
hyaluronic acid (HA) remain the mainstay of conservative treatment. The evidence for using PRP for this 
condition includes multiple RCTs and systematic reviews. Most trials have compared Platelet Rich Plasma 
(PRP) with HA for knee osteoarthritis, though HA as a comparator is questionable because the evidence 
demonstrating the benefit of HA for osteoarthritis is not robust. 
 
Systematic reviews have generally found that PRP was more effective than placebo or HA in reducing pain and 
improving function. However, systematic review authors have noted that their findings should be interpreted 
with caution due to important limitations, including significant statistical heterogeneity, questionable clinical 
significance, and a high risk of bias in study conduct. One retrospective study compared PRP to HA in 190 
patients between January 2014 and October 2017. Western Ontario and McMaster Universities Osteoarthritis 
Index (WOMAC), VAS, and ROM were measured before injection, at 15 days, six months, 12 months, and at 
last follow-up. HA treated patients experienced a higher arthroplasty rate (36.0% vs. 5.3%, p < 0.001), lower 
ROM, worse VAS and WOMAC score, and increased risk of any arthroplasty occurrence (log-rank < 0.001) 
than PRP patients. 
 
However, evidence is still limited due to the overall high risk of bias in previous trials and great variability 
between studies regarding the number of injections (generally 1 to 4), the interval between injections, 
preparation of the PRP, and volume injected. Furthermore, the typical length of follow up was only one year or 
less. There is also uncertainty regarding whether individuals with less severe OA may benefit more from this 
intervention compared with individuals with more advanced structural damage. Additionally, it is unclear whether LR-PRP or LP-PRP should be utilized, though the latter appears to have an advantage. Larger 
controlled studies comparing PRP with placebo and alternatives other than HA are needed to determine the 
efficacy of PRP for knee OA. Further studies are also needed to determine the optimal protocol for delivering 
PRP. At present, the evidence is insufficient to determine the effects of PRP on health outcomes for OA. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39058: Platelet Rich Plasma 
Injections for Non-Wound Injections. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.