Medical Policy: 02.01.60
Original Effective Date: March 2018
Reviewed: March 2019
Revised: March 2019
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 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.
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.
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 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.
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
Not applicable.
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.
Human amniotic membrane grafts with suture (e.g. AmnioGraft®) for the treatment of ophthalmic indications are considered medically necessary for the following conditions:
Sutured human amniotic membrane grafts are considered investigational for the treatment of all other ophthalmic conditions including but not limited to:
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.
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.
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.