Coverage Policies

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.

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

The available evidence regarding the effectiveness of autologous blood injection for the treatment of tendinopathies’ is largely based on non-randomized studies.  Randomized studies have not consistently supported effectiveness.  Furthermore, available guidelines from the American College of Occupational and Environmental Medicine, National Institute for Health and Clinical Excellence (NICE), and Work Loss Data Institute do not support the use of autologous blood injection for tendinopathies’. 

The American College of Occupational and Environmental Medicine (2007) did not recommend autologous blood injection for managing patients with elbow disorders.  The NICE`s guideline on autologous blood injection for tendinopathy (2009) states that current evidence on the safety and effectiveness of autologous blood injection for tendinopathy is inadequate in quantity and quality.  In addition, the NICE Committee notes that some of the published studies involved the use of dry needling prior to the injection of autologous blood, but it was not possible to differentiate between effects of these two components of the procedure.  The Committee also states that future research should be in the context of randomized controlled studies that define chronicity of tendinopathy and describe any previous or adjunctive therapies (e.g., physiotherapy and dry needling) as well as the tendons treated.  These studies should address the role of ultrasound guidance and include functional and quality of life outcomes with a minimum follow-up of 1 year.  It is also interesting to note that the Work Loss Data Institute`s guideline on the management of acute and chronic shoulder disorders (2007) did not mention the use of autologous blood injection as a means of therapy.

Besides autologous blood injection, other blood product injection therapies for the treatment of patients with tendinopathies’ include platelet-rich plasma (PRP) and bone marrow plasma.

PRP for Elbow Injuries:  In a pilot study, Mishra and Pavelko (2006) reported their findings on the treatment of chronic elbow tendinosis with PRP.  A total of 140 patients were evaluated in this study.  Subjects were initially given a standardized physical therapy protocol and various non-operative treatments.  Twenty of these patients had significant persistent pain (mean of 82 of 100; range of 60 to 100 of 100 on VAS) for a mean of 15 months despite these interventions.  All patients were considering surgery.  This cohort of patients was then given either a single percutaneous injection of PRP (n = 15) or bupivacaine (n = 5).  Eight weeks after the treatment, the PRP-injected patients noted a 60 % improvement in their VAS versus 16 % improvement in bupivacaine-treated patients (p = 0.001).  Three of 5 of the control subjects (bupivacaine-treated) withdrew or sought other treatments after the 8-week period, preventing further direct analysis.  Thus, only PRP-treated patients were available for continued evaluation.  At 6 months, PRP-treated subjects noted an 81 % improvement in their VAS (p = 0.0001).  At final follow-up (mean of 25.6 months; range of 12 to 38 months), the PRP-treated patients reported a 93 % reduction in pain compared with before the treatment (p < 0.0001).  The authors concluded that treatment of patients with chronic elbow tendinosis with PRP reduced pain significantly.  Moreover, they stated that further evaluation of this novel treatment is warranted.  Controlled studies by Creaney (2011) and Thanasas (2011) failed to show significant benefit of PRP injections compared to autologous blood injections.  A single RCT by Peerbooms (2010) did show improvement in the Disabilities of the Arm, Shoulder, and Hand score compared to corticosteroid injection.  Studies comparing PRP to sham treatment have not been reported.

PRP for ACL Injuries:  Randomized controlled trials have provided mixed results for the use of PRP in ACL injuries.  Cervellin (2012) reported that PRP improved knee function, but not pain, at one year.  Vogrin (2010) found that at 3 and 6 months after treatment with PRP during ACL surgery patients had statistically significant improvements in knee stability, but other outcome measures were not reported.  De Almeida (2012) reported improvement in patellar tendon gap area and pain score in patients who had PRP added to the patellar tendon harvest site in patients having ACL surgery; there were no significant improvements in functional outcomes or strength testing.  Orrego (2008) reported acceleration in ACL graft maturation but no improvements in functional outcomes.  Rupreht (2012) reported improvement in MRI indicators of healing at 1 and 2.5, but not at 6 months; no functional outcomes were reported.  Nin (2009) found that PRP treatment as an adjunct to ACL surgery was not associated with any significant improvements in pain or knee function.  Figueroa (2010) and Silva and Sampaio (2009) did not find any statistically significant benefits for PRP injection during ACL surgery, based on MRI and histologic exams.  Thus, there is minimal evidence for benefits.

PRP for Rotator Cuff Injuries:  Controlled studies by Rodeo (2012) and Castricini (2011) did not show any significant benefit to use of platelet-rich fibrin matrix during arthroscopic rotator cuff tendon repair.  In contract, Gumina (2012) reported better tendon repair integrity after 13 months of follow-up.  Randelli (2011) reported that autologous PRP lowered pain scores up to 30 days after surgery and improved clinical ratings scale scores at 3 months, but not thereafter.  Rha (2012) reported that two injections of PRP in patients with tendinosis or partial tears of the rotator cuff significantly improved Shoulder Pain and Disability Index scores at 6 weeks, 3 months, and 6 months compared to dry needling.

PRP for Achilles Tendon Injuries:  Two controlled trials failed to demonstrate improved outcome with use of PRP in patients with Achilles tendinopathy or tendon rupture.

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.