Description

Mesenchymal stem cells (MSCs) are multipotent cells (also called stromal multipotent cells) thatcandifferentiate into various tissues including organs, trabecular bone, tendon, articular cartilage, ligaments, muscle, and fat. MSCs are associated with the blood vessels within bone marrow, synovium, fat, and muscle, where they can be mobilized for endogenous repair as occurs with healing of bone fractures. Stimulation of endogenous MSCs is the basis of procedures such as bone marrow stimulation (e.g., microfracture) and harvesting/grafting of autologous bone for fusion.

Criteria

The following orthopedic applications are considered experimental investigational and therefore non-covered. Scientific evidence does not support the use of these procedures in the peer-reviewed literature.

• Mesenchymal stem cell therapy (including but not limited to Regenexx® Procedure)is considered experimental/investigational and therefore non-covered for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue.
• Allograft bone products containing viable stem cells, including but not limited to demineralized bone matrix (DBM) with stem cells are considered experimental/investigationalfor all orthopedic applications and therefore non-covered.
• Allograft or synthetic bone graft substitutes that must be combined with autologous blood or bone marrow are considered experimental/investigational and therefore non-covered for all orthopedic applications.

Procedure Codes

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review

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.