Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 23, 2019


A variety of growth factors have been found to play a role in wound healing, including platelet-derived growth factors (PDGF), epidermal growth factor, fibroblast growth factors, transforming growth factors, and insulin-like growth factors. Autologous platelets are a rich source of PDGF, transforming growth factors (that 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. PRP is distinguished from fibrin glues or sealants.


Recombinant platelet-derived growth factor (i.e., becaplermin [Regranex]) may be considered medically necessary when used as an adjunct to standard wound management when EITHER of the following criteria has been met:

  • Neuropathic diabetic ulcers extending into the subcutaneous tissue or beyond and have an adequate blood supply; or
  • Pressure ulcers extending into the subcutaneous tissue.

Becaplermin gel for treatment of neuropathic ulcers may be considered medically necessary when ALL of the following criteria are met:

  • Adequate tissue oxygenation of30 mm Hg or greater measured by EITHER:
    • A transcutaneous partial pressure on the foot dorsum or at the margin of the ulcer; or
    • Toe photoplethysmography (PPG) with infrared reflectance technique; and
  • Full-thickness ulcer (i.e., Stage III or IV), extending through dermis into subcutaneous tissues; and
  • Participation in a wound-management program, which includes sharp debridement, pressure relief (i.e., non-weight bearing), and infection control.

Becaplermin gel for the treatment of pressure ulcers may be considered medically necessary when ALL of the following criteria are met:

  • Full-thickness ulcer (i.e., Stage III or IV), extending through dermis into subcutaneous tissues; and
  • Ulcer in an anatomic location that can be off-loaded for the duration of treatment; and
  • Albumin concentration greater than 2.5 dL; and
  • Total lymphocyte count greater than 1,000; and
  • Normal values of vitamins A and C.

All other applications of recombinant platelet-derived growth factor (i.e., becaplermin [Regranex]) are considered experimental/investigational, and therefore, non-covered including, but not limited to, ischemic ulcers, ulcers related to venous stasis, and ulcers not extending through the dermis into the subcutaneous tissue. The safety and/or effectiveness cannot be established by review of the published peer-reviewed literature.

Procedure Codes

S0157 S9055

Use of autologous blood-derived preparations (i.e., injection of PRP) is considered experimental/investigational and therefore non-covered for ALL non-orthopedic conditions because the effectiveness cannot be established by published peer-reviewed literature.

Procedure Codes

0232T 0481T 86999 G0460 P9020

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes S0157, S9055 and 86999

E08.621 E08.622 E09.621 E09.622 E10.21 E10.40 E10.41
E10.42 E10.43 E10.49 E10.621 E10.622 E11.40 E11.41
E11.42 E11.43 E11.49 E11.621 E11.622 E13.621 E13.622
L89.43 L89.44 L89.93 L89.94 L89.003 L89.004 L89.013
L89.014 L89.023 L89.024 L89.103 L89.104 L89.113 L89.114
L89.123 L89.124 L89.133 L89.134 L89.143 L89.144 L89.153
L89.154 L89.203 L89.204 L89.213 L89.214 L89.223 L89.224
L89.303 L89.304 L89.313 L89.314 L89.323 L89.324 L89.503
L89.504 L89.513 L89.514 L89.523 L89.524 L89.603 L89.604
L89.613 L89.614 L89.623 L89.624 L89.813 L89.814 L89.893
L89.894 L89.94 L97.102 L97.103 L97.104 L97.105 L97.106
L97.108 L97.112 L97.113 L97.114 L97.115 L97.116 L97.118
L97.122 L97.123 L97.124 L97.125 L97.126 L97.128 L97.202
L97.203 L97.204 L97.205 L97.206 L97.208 L97.212 L97.213
L97.214 L97.215 L97.216 L97.218 L97.222 L97.223 L97.224
L97.225 L97.226 L97.228 L97.302 L97.303 L97.304 L97.305
L97.306 L97.308 L97.312 L97.313 L97.314 L97.315 L97.316
L97.318 L97.322 L97.323 L97.324 L97.325 L97.326 L97.328
L97.402 L97.403 L97.404 L97.405 L97.406 L97.408 L97.412
L97.413 L97.414 L97.415 L97.416 L97.418 L97.422 L97.423
L97.424 L97.425 L97.426 L97.428 L97.502 L97.503 L97.504
L97.505 L97.506 L97.508 L97.512 L97.513 L97.514 L97.515
L97.516 L97.518 L97.522 L97.523 L97.524 L97.525 L97.526
L97.528 L97.802 L97.803 L97.804 L97.805 L97.806 L97.808
L97.812 L97.813 L97.814 L97.815 L97.816 L97.818 L97.822
L97.823 L97.824 L97.825 L97.826 L97.828 L97.902 L97.903
L97.904 L97.905 L97.906 L97.908 L97.912 L97.913 L97.914
L97.915 L97.916 L97.918 L97.922 L97.923 L97.924 L97.925
L97.926 L97.928 L98.412 L98.413 L98.414 L98.415 L98.416
L98.418 L98.422 L98.423 L98.424 L98.425 L98.426 L98.428
L98.492 L98.493 L98.494 L98.495 L98.496 L98.498