Autologous Platelet-derived Growth Factors as a Primary Treatment of Wound Healing and Other Miscellaneous Conditions
 Printer-Friendly Version
Medical Policy: 02.01.32
Original Effective Date: August 2007
Reviewed:
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
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.
Autologous platelet-derived growth factors 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 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.
Plantar fasciitis occurs when the plantar fascia ligament along the bottom of the foot develops tears resulting in pain and inflammation. Common causes include physical activity or exercise overload, arthritis, and diabetes. Plantar fasciitis may also be influenced by the mechanics of the foot such as high arches, flat feet, abnormal gait, and pronation. The discomfort of plantar fasciitis is characterized by stabbing, burning, or aching in the heel of the foot where the fascia attaches to the calcaneus.
Lateral epicondylitis, commonly known as tennis elbow, is an overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus. Presenting symptoms include lateral elbow and forearm pain exacerbated by use. It has been suggested that the concentrated growth factors contained in autologous platelet-derived plasma initiates a healing response within the tendon leading to increased functionality and reduced pain.
Dupuytren’s contracture is a condition in which the pretendinous bands of the palmar fascia thickens and tightens. As the bands tighten the fingers may be pulled down toward the palm of the hand. Standard treatment involves surgical release of the contracted bands.
Policy:
Autologous platelet-derived growth factor injections 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, epicondylitis, and Dupuytren’s contracture because there is insufficient evidence in the peer-reviewed, medical literature.
 Top
Procedure Codes and Billing
Guidelines:
-
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
-
HCPCS code S9055 Procuren or other growth factor preparation to promote wound healing
Top
Selected References:
-
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.
Top
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2007 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
|
 |
