Medical Policy: 02.01.60 

Original Effective Date: March 2018 

Reviewed: March 2019 

Revised: March 2019 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

Benefit Application:

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.

 

Description:

There are many products available using amnion, chorion, amniotic fluid, and umbilical cord that are being studied for the treatment of a variety of conditions. Frequently this is referred to as human amniotic membrane (HAM) by grafting or by injection. Human amniotic membrane (HAM) consists of 2 conjoined layers, the amnion and chorion, and forms the innermost lining of the amniotic sac or placenta. When prepared for use, the membrane is harvested immediately after birth, cleaned, sterilized, and either cryopreserved or dehydrated.

 

Conditions being studied include chronic full thickness diabetic lower extremity ulcers, venous ulcers, knee osteoarthritis, plantar fasciitis, tendonitis, cartilage damage, for alleviation of pain and stiffness, and for ophthalmic surface disorders.

 

Amniotic Injections and Fluid

When administered by injection human amniotic tissue is micronized, or reduced in particle size to a form that can be suspended in liquid. Multiple products are available for injection. They include AmnioFix® Injectable (MiMedx), Clarix® Flo and Neox® Flo (Amniox), AmnioMatrix® (Derma Sciences), AmnioPro™ (Human Regenerative Technologies), and AmnioGen™ (US Biologix). Amniotic fluid products that are cryopreserved and contain living cells include AmnioVisc™ (previously named AmnioClear® LCT from Liventa Bioscience) and OrthoFlo™ (MiMedx). PalinGen® Flow and Sport Flow™ (Amnio ReGen Solutions) contains cryopreserved amniotic fluid and cryofractured amniotic membrane. ReNu™ (NuTech Medical) is composed of a human amniotic membrane suspension along with amniotic fluid derived cells.

 

Amniotic Serum Drops/Umbilical Cord Serum Drops

Amniotic membrane extract may be combined with umbilical cord (UC) blood as another type of amniotic membrane-derived solution. Drops made from amniotic fluid, reconstituted dehydrated amnion or morselized amniotic tissue will soon be available in the United States.

 

Amniotic Fluid for Ophthalmologic Use

HAM graft that is fixated by sutures or glue or secured under a bandage contact lens is an established treatment for disorders for the corneal surface. Non-fixated amniotic patch within a flexible ring that is inserted like a contact lens has more recently been investigated for the treatment of corneal and ocular surface disorders.

 

For information on amniotic membranes for use as skin substitutes see medical policy 02.01.17

 

Prior Approval:

Not applicable.

 

Policy:

Injectables/Liquid

Injection of micronized or particulated human amniotic membrane is considered investigational for all indications.

 

Injections of human amniotic fluid is considered investigational for all indications.

 

Additional trials, which will have a larger sample sizes and longer follow-up, are needed to permit conclusions on the effect of this treatment. The evidence is insufficient to determine the effects of the technology on health outcomes.

 

Ophthalmic Use

Human amniotic membrane grafts with suture (e.g. AmnioGraft®) for the treatment of ophthalmic indications are considered medically necessary for the following conditions:

  • Neurotrophic keratitis (degenerative disease of the cornea caused by damage of the trigeminal nerve)
  • Corneal ulcers (open sore on the cornea, usually as the result of an infection)
  • Keratolysis or corneal melts (sterile melting of the cornea, may occur following cataract extraction)
  • Pterygium (tissue growth on the cornea) repair
  • Stevens-Johnson syndrome (severe skin reaction to certain medications)

 

Sutured human amniotic membrane grafts are considered investigational for the treatment of all other ophthalmic conditions including but not limited to:

  • Dry eye syndrome
  • Burns
  • Corneal perforation
  • Bullous keratopathy
  • Limbus stem cell deficiency
  • Mooren’s ulcer
  • Restrictive strabismus
  • After photorefractive keratectomy

 

Human amniotic membrane without suture (eg, Prokera®, AmbioDisk™) for ophthalmic indications is considered investigational.

 

Amniotic Serum Drops/Umbilical Cord Serum Drops (e.g. Regener-Eyes, Genesis) are considered investigational

 

Traditionally, amniotic membrane has been sutured onto the eye for a variety of ocular surface disorders. There is a belief that using stitches allows the membranes to stay in contact with the affected surfaces longer. Amniotic membrane typically dissolves over a period of one or two weeks. Results from 2 recent RCTs have suggested benefit, but the studies are at high or uncertain risk of bias due to unequal baseline scores and the lack of masking (blinding). Additional study in a larger number of subjects is needed to demonstrate consistent effects. The Prokera device is novel by having a ring around the c-HAM allograft that allows it to be inserted under topical anesthesia similar to insertion of a contact lens, allowing for more widespread use. Current evidence on use of the Prokera device includes case reports and case series. Results are generally positive, but controlled studies are needed.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • Q4100 Skin substitute, not otherwise specified (AmnioFix or OrthoFlo)
  • Q4139 Amniomatrix or biodmatrix, injectable, 1cc
  • Q4145 Epifix, injectable, 1mg
  • Q4155 NeoxFlo or ClarixFlo, 1mg
  • Q4162 Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5cc
  • Q4174 PalinGen or ProMatrX, 0.36 mg per 0.25 cc
  • Q4177 FlowerAmnioFlo, 0.1cc
  • Q4185 Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc
  • Q4186 Epifix, per sq cm
  • Q4189 Artacent AC, 1 mg
  • Q4192 Restorigin, 1 cc
  • Q4202 Keroxx (2.5g/cc), 1cc  V2790 Amniotic membrane for surgical reconstruction, per procedure
  • Q4205 Membrane graft or membrane wrap, per square centimeter
  • Q4206 Fluid flow or fluid GF, 1 cc
  • Q4208 Novafix, per square cenitmeter
  • Q4209 Surgraft, per square centimeter
  • Q4210 Axolotl graft or axolotl dualgraft, per square centimeter 
  • Q4211 Amnion bio or Axobiomembrane, per square centimeter
  • Q4212 Allogen, per cc
  • Q4213 Ascent, 0.5 mg 
  • Q4214 Cellesta cord, per square centimeter 
  • Q4215 Axolotl ambient or axolotl cryo, 0.1 mg
  • Q4216 Artacent cord, per square centimeter
  • Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter
  • Q4218 Surgicord, per square centimeter
  • Q4219 Surgigraft-dual, per square centimeter
  • Q4221 Amniowrap2, per square centimeter 
  • V2790 Amniotic membrane for surgical reconstruction, per procedure
  • 65778 Placement of amniotic membrane on the ocular surface, without sutures
  • 65779 Placement of amniotic membrane on the ocular surface, single layer, sutured
  • 66999 Unlisted procedure, anterior segment of eye (Deny for tissue graft using glue)

 

Selected References:

  • Suri, K., Kosker, M., Raber, I., Hammersmith, K., Nagra, P., Ayres, B., et al. (2013, September) Sutureless amniotic membrane ProKera for ocular surface disorders: short-term results. Eye Contact Lens, 39(5):341-7. Abstract retrieved May 22, 2017 from PubMed database.
  • Chavez-Garcia C, Jimenez-Corona A, Graue-Hernandez EO, et al. Ophthalmic indications of amniotic membrane transplantation in Mexico: an eight years Amniotic Membrane Bank experience. Cell and tissue banking. Dec 16 2015.
  • Katircioglu YA, Altiparmak U, Engur Goktas S, Cakir B, Singar E, Ornek F. Comparison of Two Techniques for the Treatment of Recurrent Pterygium: Amniotic Membrane vs Conjunctival Autograft Combined with Mitomycin C. Seminars in ophthalmology. Dec 2015;30(5-6):321-327.
  • Palamar M, Kaya E, Egrilmez S, Akalin T, Yagci A. Amniotic membrane transplantation in surgical management of ocular surface squamous neoplasias: long-term results. Eye (London, England). Sep 2014;28(9):1131-1135.
  • Schallenberg M, Westekemper H, Steuhl KP, Meller D. Amniotic membrane transplantation ineffective as additional therapy in patients with aggressive Mooren's ulcer. BMC ophthalmology. 2013;13:81.
  • Sharma N, Thenarasun SA, Kaur M, et al. Adjuvant Role of Amniotic Membrane Transplantation in Acute Ocular Stevens-Johnson Syndrome: A Randomized Control Trial. Ophthalmology. Mar 2016;123(3):484-491.
  • Siu GD, Young AL, Cheng LL. Long-term symptomatic relief of bullous keratopathy with amniotic membrane transplant. International ophthalmology. Dec 2015;35(6):777-783.
  • Shimberg M, Wadsworth K. The use of amniotic-fluid concentrate in orthopaedic conditions. Jf Bone Joint Surg. 1938; 20(1): 167-177.
  • Tsikopoulos K, Vasiliadis HS, Mavridis D. Injection therapies for plantar fasciopathy ('plantar fasciitis'): a systematic review and network meta-analysis of 22 randomised controlled trials. Br J Sports Med. Nov 2016; 50(22):1367-1375.
  • Vines JB, Aliprantis AO, Gorroll AH, et al. Cryopreserved Amniotic Suspension for the Treatment of Knee Osteoarthritis. J Knee Surg. Dec 18 2015.
  • U.S. Food and Drug Administration. Guidance for industry: Chronic cutaneous ulcer and burn wounds. 2006;
  • Clare G, Suleman H, Bunce C, et al. Amniotic membrane transplantation for acute ocular burns. Cochrane Database Syst Rev. 2012;9:CD009379. PMID 22972141
  • Cheng, et. al . Morselized Amniotic Membrane Tissue for Refractory Corneal
  • Epithelial Defects. Transl Vis Sci Technol. 2016 May; 5(3).
  • Murri MS, Moshirfar M1, Birdsong OC, Ronquillo YC, Ding Y, Hoopes PC. Amniotic membrane extract and eye drops: a review of literature and clinical application. Clin Ophthalmol. 2018 Jun 18;12:1105-1112. doi: 10.2147/OPTH.S165553. eCollection 2018
  • Jirsova K, Jones GLA. Amniotic membrane in ophthalmology: properties, preparation, storage and indications for grafting-a review.Cell Tissue Bank. 2017 Jun;18(2):193-204. doi: 10.1007/s10561-017-9618-5. Epub 2017 Mar 2. Review. PMID: 28255771
  • Management of recalcitrant corneal ulcers with dry processed amniotic membrane. Bhatia J, Narayanadas B, Varghese M, Mansi MA, Mohamed MF, Gad AAH, Bhatia N. Oman J Ophthalmol. 2019 Jan-Apr;12(1):68-69. doi: 10.4103/ojo.OJO_95_2018.

 

Policy History:

  • March 2019 - Annual Review, Policy Revised
  • March 2018 - New Policy

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.

 

*CPT® is a registered trademark of the American Medical Association.