Covered Service

Extended Definition

A covered service is any medical service, procedure, or treatment that your insurance plan includes in its list of benefits. However, being a “covered service” doesn’t mean insurance pays 100%—you may still owe deductibles, copays, or coinsurance.

Covered vs. Paid

Covered means:

• The service is in your plan benefits
• Insurance will process the claim
• You may still owe your share

Not covered means:

• Insurance won’t pay anything
• You’re responsible for full cost
• Doesn’t count toward deductible/OOPM

Common Coverage Status for Joint Pain

Treatment	Medicare Part B	Typical Private
HA injections	Covered	Usually covered
Corticosteroid	Covered	Covered
Physical therapy	Covered	Covered (limits vary)
PRP	Not covered	Usually not covered
Stem cells	Not covered	Not covered
X-rays	Covered	Covered
MRI	Covered	Covered (may need PA)

Requirements for Coverage

Even covered services may require:

• Prior authorization
• Medical necessity documentation
• Network provider use
• Step therapy compliance
• Referral from PCP

Verifying Coverage

Before treatment, confirm:

1. Is the service listed as covered?
2. What are the cost-sharing requirements?
3. Is prior authorization needed?
4. Does the provider accept your insurance?
5. Are there any limits (frequency, quantity)?

If a Covered Service Is Denied

Coverage denial may occur if:

• Medical necessity not established
• Requirements not met
• Annual limits exceeded
• Documentation incomplete

You have the right to appeal covered service denials.