DESCRIPTION
Platelet-rich plasma (PRP) is defined as a platelet-rich concentrate with platelet levels greater than the baseline platelet count in whole blood. This autologous derived substance is also referred to as autologous platelet-derived growth factors, platelet gel, platelet-rich concentrate, autogenous platelet gel, or platelet releasate. PRP has been proposed for the treatment of multiple conditions to enhance healing; however, the role that white blood cells may play is particularly unclear. Furthermore, PRP preparations are not standardized and exhibit wide variability in platelet and white blood cell concentrations and the use of thrombin activators. Some providers combine platelet-rich plasma with adipose cells, in addition, other agents may be added to the mix; the solution is then injected into various locations on the body. Some providers refer to this procedure as “fat graft stem cell treatment”.
POLICY
Platelet rich plasma for the treatment of all conditions/diseases, including, but not limited to, wound healing is considered investigational.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Current results of trials using PRP are mixed, and the studies are limited in both size and quality. The evidence is insufficient to determine the effects of this technology on health outcomes.
SOURCES
Al-Moraissi, Wolford, L.M., Ill, E.E., & Neff, A. (2020). The hierarchy of different treatments for arthrogenous temporomandibular disorders: A network meta-analysis of randomized clinical trials. Journal of Cranio-Maxillo-Facial Surgery, 48 (1), 9-23. (Level 2 evidence)
American Academy of Orthopaedic Surgeons. Management of osteoarthritis of the knee – evidence-based clinical practice guideline 3rd edition. Retrieved July 15, 2022 from https://www.aaos.org.
American Academy of Orthopaedic Surgeons. Management of osteoarthritis of the hip – evidence-based clinical practice guideline. Retrieved July 15, 2022 from https://www.aaos.org.
BlueCross BlueShield Association. Evidence Positioning System. (2:2023). Recombinant and autologous platelet-derived growth factors for wound healing and other non-orthopedic conditions (2.01.16). Retrieved October 26, 2023 from www.bcbsaoca.com/eps/. (75 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (3:2023) Temporomandibular joint disorder (2.01.21). Retrieved October 26, 2023 from www.bcbsaoca.com/eps/. (45 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (5:2023). Orthopedic applications of platelet-rich plasma (2.01.98). Retrieved October 26, 2023 from www.bcbsaoca.com/eps/. (68 articles and/or guidelines reviewed)
Centers for Medicare & Medicaid Services. CMS.gov. (2021). NCD for blood-derived products for chronic non-healing wounds (270.3). Retrieved July 14, 2022 from http://www.cms.gov.
Chung, P-Y., L, M-T., & Chang, H-P. (2018). Effectiveness of platelet-rich plasma injection in patients with temporomandibular joint osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Oral and Maxillofacial Surgery, 127 (2), 106-116. Abstract retrieved August 11, 2020 from PubMed database.
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2023, March). Platelet rich plasma. (LCD ID L38745). Retrieved October 26, 2023 from https://www.cms.gov.
de Souza, T.E., de Castro, T.F., Michellon, F.C., Passoni, A.C.C., Ortega, L.J.A., Iwaki, L.C.V., & da Siva, M.C. (2019). Adjuvant therapies in the management of medication-related osteonecrosis of the jaws: systematic review. Head & Neck, 41 (12), 4209-4228. Abstract retrieved September 23, 2019 from PubMed database.
Di Matteo, B., Loibl, M., Andriolo, L., Filardo, G., Zellner, J., Koch, M., & Angele, P., (2016). Biologic agents for anterior cruciate ligament healing: a systematic review. World Journal of Orthopedics, 7 (9), 592-603. (Level 1 evidence)
Fitzpatrick, J., Bulsara, M., & Zheng, M. (2017). The effectiveness of platelet-rich plasma in the treatment of tendinopathy: a meta-analysis of randomized controlled clinical trials. American Journal of Sports Medicine, 45 (1), 226-233. Abstract retrieved September 23, 2019 from PubMed database.
Franchini, M., Cruciani, M., Mengoli, C., Marano, G., Pupella, S., Veropalumbo, E., et al. (2018). Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis. Blood Transfusion, 16 (6), 502-513. (Level 2 evidence)
Gupta, S., Paliczak, A., & Delgado, D. (2021). Evidence-based indications of platelet-rich plasma therapy. Expert Review of Hematology, 14 (1), 97-108. Abstract retrieved October 26, 2023 from PubMed database.
Johal, H., Khan, M., Yung, S.P., Dhillin, M.S., Fu, F.H., Bedi, A., & Bhandari, M. (2019). Impact of platelet-rich plasma use on pain in orthopaedic surgery: a systematic review and meta-analysis. Sports Health, 11 (4), 355-366. (Level 1 evidence)
Kuang, M., Han, C., Ma, J., Li, F., Zhao, J., Fu, L., & Ma, X. (2016). The efficacy of intraoperative autologous platelet gel in total knee arthroplasty: a meta-analysis. International Journal of Surgery, 36 (pt A), 56-65. (Level 1 evidence)
Ling, Y. & Wang, S. (2018). Effects of platelet-rich plasma in the treatment of plantar fasciitis: a meta-analysis of randomized controlled trials. Medicine, 97 (37), e12110. (Level 2 evidence)
Lopez-Jornet, P., Sanchez Perez, A., Mendes, A., & Tobias, A. (2016). Medication-related osteonecrosis of the jaw: Is autologous platelet concentrate application effective for prevention and treatment? A systematic review. Journal Craniomaxillofacial Surgery, 44 (8), 1067-1072. Abstract retrieved November 11, 2016 from PubMed database.
National Institute for Health and Clinical Excellence (NICE). (2013, January). Autologous blood injection for plantar fasciitis. Retrieved May 28, 2013 from http://www.nice.org.uk/guidance/.
National Institute for Health and Clinical Excellence (NICE). (2019, January). Platelet-rich plasma injections for knee osteoarthritis. Retrieved August 10, 2020 from http://www.nice.org.uk/guidance/.
National Institute for Health and Clinical Excellence (NICE). (2013, January). Autologous blood injection for tendinopathy. Retrieved November 11, 2016 from http://www.nice.org.uk/guidance/.
Suthar, M. Gupta, S., Bukhari, S., & Ponemone, V. (2017). Treatment of chronic non-healing ulcers using autologous platelet rich plasma: a case series. Journal of Biomedical Science, 24 (16). (Level 4 evidence)
Winifred S. Hayes Inc. Health Technology Assessment (2021, October; last update search December 2022). Platelet-rich plasma for wound treatment in venous leg ulcers. Retrieved October 26, 2023 from www.Hayesinc.com/subscribers. (43 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Clinical Research Response. (2021, August). Platelet rich plasma for spinal fusion. Retrieved 7/14/2022 from www.Hayesinc.com/subscribers. (13 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Clinical Research Response. (2022, February). Platelet rich plasma in infertility treatment programs. Retrieved 7/14/2022 from www.Hayesinc.com/subscribers. (38 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Health Technology Assessment. (2022, February; last update search April 2023). Platelet-rich plasma for wound treatment in diabetic foot ulcers. Retrieved October 26, 2023 from www.Hayesinc.com/subscribers. (51 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, December; last update search January 2022). Platelet-rich plasma for treatment of lateral epicondylitis: a review of reviews. Retrieved July 14, 2022 from www.Hayesinc.com/subscribers. (48 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, December; last update search January 2022). Platelet-rich plasma for treatment of tendinopathies or ligament injuries of the knee. Retrieved July 14,2022 from www.Hayesinc.com/subscribers. (41 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, November; last update search January 2022). Platelet-rich plasma for knee osteoarthritis: a review of reviews. Retrieved July 14, 2022 from www.Hayesinc.com/subscribers. (48 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, March; last update search February 2022). Platelet-rich plasma for treatment of conditions of the Achilles tendon and plantar fascia. Retrieved July 14, 2022 from www.Hayesinc.com/subscribers. (52 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, May; last update search July 2021). Platelet-rich plasma for rotator cuff repairs, tendinopathies, and related conditions: a review of reviews. Retrieved July 14, 2022 from www.Hayesinc.com/subscribers. (72 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2019, June; last update search June 2022). Platelet-rich plasma for hip osteoarthritis. Retrieved October 26, 2023 from www.Hayesinc.com/subscribers. (32 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 1/14/2012
MOST RECENT REVIEW DATE: 12/14/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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