Orthopedic Applications of Platelet-Rich Plasma

Policy ID: S-265-005

Section: Surgery

Effective Date: November 02, 2020

Revised Date: November 21, 2024

Revision Effective Date: January 06, 2025

Last Reviewed: November 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

The use of platelet-rich plasma (PRP) has been proposed as a treatment for various musculoskeletal conditions and as an adjunctive procedure in orthopedic surgeries.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Use of PRP is considered experimental/investigational , and therefore non-covered , for all orthopedic indications because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.

Procedure Codes

0232T

P9020

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Newly adopted policy

Internal Medical Policy Committee 9-21-2021 Annual Review with no changes in criteria

Internal Medical Policy Committee 5-24-2022 Coding update

Removed 86999

Internal Medical Policy Committee 9-19-2024 Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-265-004

Section: Surgery

Effective Date: November 02, 2020

Revised Date: May 20, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: January 05, 2025

Applies To: Commercial and Medicaid Expansion

Description

The use of platelet-rich plasma (PRP) has been proposed as a treatment for various musculoskeletal conditions and as an adjunctive procedure in orthopedic surgeries.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Use of PRP is considered experimental/investigational, and therefore non-covered,for all orthopedic indications because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.

Procedure Codes

0232T

P9020

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Newly adopted policy

Internal Medical Policy Committee 9-21-2021 Annual Review with no changes in criteria

Internal Medical Policy Committee 5-24-2022 Coding update

Removed procedure code 86999

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - no changes in criteria

Added Policy Application

Links

References (PDF)

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