Medical Policy
Effective Date:12/08/2010 Title:Platelet Rich Plasma
Revision Date:03/01/2017 Document:BI288:00
CPT Code(s):P9020, 0232T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Platelet rich plasma injections are not covered.

2)    Platelet rich plasma is injected into areas around damaged tendons with the intent of stimulating healing.
Medical Statement

Blood products including platelet rich plasma used in the treatment of joints and tendinopathies’, or for any other reason, are considered experimental/investigational and are not covered.

 

Codes Used In This BI:

P9020 - Platelet rich plasma unit

0232T - Injection platelet plasma
Limits
Intentially left empty
Reference
  1. Suresh SP, Ali KE, Jones H, Connell DA. Medial epicondylitis: Is ultrasound guided autologous blood injection an effective treatment? Br J Sports Med. 2006; 40(11):935-939; discussion 939.
  2. Connell DA, Ali KE, Ahmad M, et al. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006; 35(6):371-377.
  3. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006; 34(11):1774-1778.
  4. James SL, Ali K, Pocock C, Robertson C, et al. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007; 41(8):518-521; discussion 522.
  5. American College of Occupational and Environmental Medicine (ACOEM). Elbow disorders. Elk Grove Village, IL: American College of Occupational and Environmental Medicine (ACOEM); 2007.
  6. Work Loss Data Institute. Shoulder (acute & chronic). Corpus Christi, TX: Work Loss Data Institute; July 5, 2007.  
  7. Moon YL, Jo SH, Song CH, et al. Autologous bone marrow plasma injection after arthroscopic debridement for elbow tendinosis. Ann Acad Med Singapore. 2008; 37(7):559-563.
  8. National Institute for Health and Clinical Excellence (NICE). Autologous blood injection for tendinopathy. Interventional Procedure Guidance 279. London, UK: NICE; January 2009. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG279Guidance.PDF . Accessed November 8, 2010. 
  9. Rompe JD, Furia JP, Maffulli N. Mid-portion Achilles tendinopathy -- current options for treatment. Disabil Rehabil. 2008; 30(20-22):1666-1676.
  10. Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylitis: Prolotherapy, polidocanol, whole blood and platelet rich plasma. Br J Sports Med. 2009 Jan 21. [Epub ahead of print].
  11. Hayes Medical Technology Assessment.  Platelet-Rich Plasma for Ligament and Tendon Injuries.  Published Dec 24, 2012.
  12. Castricini R, et al. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair:  a randomized controlled trial. Am J Sports Med 2011; 39(2):258-265.
  13. Cervellin M, et al. Autologous platelet-rich plasma gel to reduce donor-site morbidity after patellar tendon graft harvesting for anterior cruciate ligament reconstruction: a randomized, controlled clinical study.  Knee Surg Sports Traumatol Arthrosc. 2012;20(1):114-120
  14. Creaney L, et al.  Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, dingle-blind, randomized trial of autologous blood injections versus platelet-rich plasma injections.  Br J Sports Med 2011;45(12):966-971
  15. De Almeida AM, et al.  Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial.  Am J Sports Med 2012;40(6): 1623-1629
  16. Peerbooms JC, et al.  Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up.  Am J Sports Med 2010;38(2):255-262
  17. Thanasas C, et al. Platelet-rich plasma versus authologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med 2011;39(10):2130-2134
  18. Vogrin M, et al. The effect of platelet-derived growth factors on knee stability after anterior cruciate ligament reconstruction:  a prospective randomized clinical study.  Wein Klin Wochenschr 2010; 122(Suppl 2):91-95
  19. Orrego M, et al.  Effects of platelet concentrate and a bone plug on the healing of hamstring tendons in a bone tunnel. Arthroscopy 2008;24(12):1373-1380
  20. Nin JR, et al.  Has platelet-rich plasma any role in anterior cruciate ligament allograft healing?   Arthroscopy 2009;25(11):1206-1213
  21. Figueroa D, et al.  Magnetic resonance imaging evaluation of the integration and maturation of semitendinosus-gracilis graft in anterior cruciate ligament reconstruction using autologous platelet concentrate. Arthroscopy 2010; 26(10):1318-1325.
  22. Silva A, Sampaio R. Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing? Knee Surg Sports Traumatol Arthrosc 2009; 17(6):676-682.
  23. Rodeo SA, et al.  The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: a prospective, randomized clinical study.  Am J Sports Med 2012;40(6):1234-1241
  24. Randelli P, et al.  Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011;20(4):518-528
  25. Browning SR, Weiser AM, et. al. Platelet-Rich Plasma Increases Matrix Metalloproteinases in Cultures of Human Synovial Fibroblasts. J Bone Joint Surg Am, 2012 Dec 05; 94(23): e172.
  26. Cavallo C, Filardo G, et. al. Comparison of Platelet-Rich Plasma Formulations for Cartilage Healing. J Bone Joint Surg Am 2014 Mar 05; 96(5) 423-429.
  27. Feller J. Platelet-Rich Plasma Injections Were Not Better Than Hyaluronic Acid Injections for Knee Joint Degeneration. J Bone Joint Surg Am 2016 Feb 17; 98(4): 315.

Addendum: 

1.     Effective 03/01/2017: Updated references.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.