Medical Policy: 02.01.32
Original Effective Date: August 2007
Reviewed: February 2015
Revised: February 2015
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Autologous platelet-derived growth factors (PDGF) have been investigated as wound healing products. For example, platelets are a rich source of platelet-derived growth factors, transforming growth factors (which function as a mitogen for fibroblasts, smooth muscle cells, and osteoblasts), and vascular endothelial growth factors. Autologous platelet concentrate suspended in plasma, also known as platelet-rich plasma (PRP), can be prepared from samples of centrifuged autologous (the patient’s own) blood. Exposure to a solution of thrombin and calcium chloride results in the polymerization of fibrin from fibrinogen, creating a platelet gel. The platelet gel can then be applied to wounds or may be used as an adjunct to surgery to promote hemostasis and accelerate healing. Activated platelets then degranulate, releasing the various growth factors.
Growth factors are proteins binding to receptors on the cell surface where they activate cellular proliferation and/or differentiation. Many are quite versatile and capable of stimulating cellular division in different cell types; while others are specific to a particular cell type. Growth factors can be obtained either by using recombinant DNA technology or through centrifuged autologous blood. Autologous platelet-derived growth factors have been hypothesized to contribute to healing of chronic wounds as well as the healing of various injured tendons and ligaments. There are a number of commercially available centrifugation devices used for the preparation of platelet-rich plasma.
A number of commercially available centrifugation devices are used for the preparation of platelet-rich plasma. For example, AutoGel™ (Cytomedix) and SafeBlood® (SafeBlood Technologies) are two related but distinct autologous blood-derived preparations that can be prepared at the bedside for immediate application. Both AutoGel and SafeBlood have been specifically marketed for wound healing. Other devices may be used in the operating room setting. Filtration or plasmapheresis can also be used to produce platelet-rich plasma.
National Institute for Health and Care Excellence (NICE) 2014
Current evidence on platelet-rich plasma injections for osteoarthritis of the knee raises no major safety concerns; however, the evidence on efficacy is inadequate in quality. Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit or research.
American Academy of Orthopaedic Surgeons (AAOS) Treatment of Osteoarthritis of the Knee 2nd edition. We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Autologous platelet-derived growth factor injections, platelet rich plasma, and autologous platelet gels are considered investigational for all indications including, but not limited to:
- As a treatment of chronic non-healing wounds
- Plantar fasciitis
- Chronic Achilles tendinopathy
- Dupuytren's contracture
- ACL reconstruction
- Rotator cuff repair
- Spinal fusion
- Osteochondral lesions
- Ganglion cyst
- Long bone non-union
- Osteonecrosis of the jaw
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 0232T Injecton(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed
- G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
- S9055 Procuren or other growth factor preparation to promote wound healing
Kiter E, Celikbas, E, Akkaya S et al. Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial. J Am Podiatr Med Assoc. 200696(4):293-6.
Logan LR, Klamar K, Leon J et al. Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity. Am J Phys Med Rehabil. 2006;85(8):699-703.
Barrett SJ, Erredge SE. Growth factors for chronic plantar fasciitis. Podiatry Today. 2004;17(11):36-42.
Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg 2004; 114(6):1502-8.
McAleer JP, Kaplan E, Persich G. Efficacy of concentrated autologous platelet-derived growth factors in chronic lower-extremity wounds. J Am Podiatr Med Assoc 2006; 96(6):482-8.
Mishra A, Pavelko T. Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma. Am J Sports Med 2006; 34(11):1774-8.
- Martinez-Zapata MJ, Marti-Carvajal A, Sola I et al. Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration: a systematic review. Transfusion 2009; 49(1):44-56.
- Mishra A, Woodall J Jr, Vieira A. Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med 2009; 28(1):113-25.
- Kon E, Buda R, Filardo G et al. Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc. 2009 Oct 17. [Epub ahead of print]
- de Vos RJ, Weir A, van Schie HTM et al. Platelet-rich plasma injection for chronic Achilles tendinopathy. A Randomized Controlled Trial. JAMA. 2010; 303(2):144-49.
- Almdahl SM, Veel T, Halvorsen P et al. Randomized prospective trial of saphenous vein harvest site infection after wound closure with and without topical application of autologous platelet-rich plasma. Eur J Cardiothorac Surg. 2011 Jan;39(1):44-8. Epub 2010 Jul 15.
- Castillo TN, Pouliot MA, Kim HJ et al. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med. 2011 Feb;39(2):266-71. Epub 2010 Nov 4.
- Peerbooms JC, Sluimer J, Bruijn DJ et al. Positive effect of an autologous platelet concentrate in laterla 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 Feb;38(2):255-62.
- Kazakos K, Lyras DN, Verettas D et al. The use of autologous PRP gel as an aid in the management of acute trauma wounds. Injury. 2009 Aug;40(8):801-5. Epub 2008 Aug 13.
- Castricini R, Longo UG, De Benedetto M et al. Platelet-rich plasma augmentation for athroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med. 2011 Feb;39(2):258-65. Epub 2010 Dec 15.
- Margolis DJ, Bartus C, Hoffstad O et al. Effectiveness of recombinant human platelet-derived growth factor for the treatment of diabetic neuropathic foot ulcers. Wound repair Regen 2005; 13(6):531-6.
- Niezgoda JA, Van Gils CC, Frykberg RG et al. Randomized clinical trial comparing OASIS Wound Matrix to Regranex Gel for diabetic ulcers. Adv Skin Wound Care 2005; 18(5 pt 1):258-66.
- ECRI. Platelet-derived Growth Factors for Treating Chronic, Nonhealing Wounds. Health Technology Assessment Service. Plymouth Meeting (PA): ECRI Institute; 2012 March 20. [Hotline Service].
- ECRI. Growth Factors for Treating Chronic Plantar Fasciitis. Health Technology Assessment Service. Plymouth Meeting (PA): ECRI Institute; 2012 March 20. [Hotline Service].
- Sheth U, Simunovic N, Klein G, et al. Efficacy or autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis. J Bone Joint Surg Am. 2012 Feb 15; 94(4):298-307.
- Carter MJ, Fylling CP, Parnell LK. Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis. Eplasty. 2011;11:e38. Epub 2011 Sep 15.
- Martinez-Zapata MJ et al. Autologous platelet-rich plasma (PRP) for chronic wounds. Cochrane Summaries. 2012 Oct. 17 Accessed [Accessed May 28, 2013]
- National Institute for Health and Clinical Excellence. Autologous blood injection for plantar fasciitis. NICE interventional procedure guidance 437. 2013.
- American Academy of Orthopaedic Surgeons, clinical practice guideline (CPG) on the treatment ofosteoarthritis of the knee 2nd Edition. May 2013, found at: http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp
Date Reason Action
August 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
May 2013 Annual review Policy revised
April 2014 Annual review Policy revised
February 2015 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
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and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.