CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Platelet-rich plasma (PRP) for orthopedic indications

This medical policy defines Blue Cross Blue Shield of Rhode Island's coverage stance on autologous platelet-rich plasma (PRP) used for orthopedic indications, including primary injections for tendinopathies, soft-tissue injuries, osteochondral lesions, osteoarthritis, and as an adjunct to orthopedic surgery. It also lists specific CPT/HCPCS codes considered not covered or not medically necessary for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPlatelet-rich plasma (PRP) for orthopedic indications

Policy CodePolicy N/A

Change TypeNo material clinical/coverage changes

Effective Date

Next Review Date

Key ActionRefer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable coverage and do not bill members for services deemed not medically necessary unless they have been informed and agreed in advance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — policy continues previous stance (has_material_change=false).

MultipleIndications reviewed

3Codes not covered

InsufficientEvidence certainty

Coverage Summary

Scope: This policy defines Blue Cross Blue Shield of Rhode Island's coverage stance on autologous platelet-rich plasma (PRP) used for orthopedic indications, including primary injections for tendinopathies, soft-tissue injuries, osteochondral lesions, osteoarthritis, and as an adjunct to orthopedic surgery. Specific CPT/HCPCS codes are listed as not covered / not medically necessary for Medicare Advantage and Commercial products.

Overview: Platelet-rich plasma for orthopedic indications is designated not_covered_cosmetic with policy status CURRENT because the evidence is insufficient to determine an improvement in net health outcome for these uses. Benefits may vary between groups and contracts; providers should refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable coverage and billing rules.

Key policy at-a-glance

Indications ReviewedMultiple indications reviewed (tendinopathy, plantar fasciitis, osteoarthritis, osteochondral lesions, adjunct to surgery)

Not-covered CPT/HCPCS codes listed3

Evidence certaintyInsufficient

Policy Statements & Evidence-based Conclusions

Policy Statement - Orthopedic Indications

Use of platelet-rich plasma (PRP) for orthopedic indications:

Use of platelet-rich plasma is not covered for all orthopedic indications as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome

Clinical Evidence Summaries (by indication)

Evidence conclusions summarized per indication (supporting the policy statement):

Indications reviewed

Tendinopathy: Primary treatment for tendinopathy: multiple RCTs and meta-analyses with mixed findings; evidence insufficient to determine net health benefit
Plantar fasciitis / Non-tendon soft tissue injury: Primary treatment for non-tendon soft tissue injury/inflammation (eg, plantar fasciitis): small RCTs and systematic reviews; inconsistent results; evidence insufficient
Osteochondral lesions: Primary treatment for osteochondral lesions: open-label quasi-randomized study; evidence insufficient
Knee or hip osteoarthritis: Primary treatment for knee or hip osteoarthritis: multiple RCTs and systematic reviews; heterogeneity and bias limit conclusions; evidence insufficient
Adjunct to surgery (ACL reconstruction, hip fracture, bone nonunion, rotator cuff repair, spinal fusion, subacromial decompression, total knee arthroplasty): multiple RCTs/reviews with mixed or negative findings; evidence insufficient

Coding

Not covered / not medically necessary codes (Medicare Advantage and Commercial)mixedNot Covered

0232T	Injection(s), platelet rich plasma, any site, including image guidance, harvest and preparation when performed
P9020	Platelet rich plasma, each unit
C1734	Orthopedic/ device/ c matrix for Opposing bone-to-bone or soft tissue-to bone (implantable) drug

Related/other PRP-related codeCPT

0481T

Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance; harvesting and preparation, when performed

Provider Actions & Billing Rules

Documentation Required

Refer to benefit booklet/contract

Benefits may vary between groups and contracts; providers should refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable coverage.

Billing Rule

Do not bill covered plans for not medically necessary PRP

For services determined to be not medically necessary or non-covered benefits, providers may not charge the member unless the member has been informed and agreed in advance to continue treatment at their own expense; follow participation agreement provisions.

Background

PRP is an autologous platelet concentrate prepared from centrifuged autologous blood that contains platelets and multiple growth factors proposed to promote healing. Preparation methods, devices, and activation procedures differ (eg, exposure to thrombin and calcium) and produce variable platelet concentrations and growth factor content, which increases variability between studies of clinical efficacy.

The FDA has cleared certain PRP preparation systems through the 510(k) pathway for use with bone materials to enhance grafting; however, use of PRP outside those cleared surgical settings (for example, office injections) is considered off-label. A variety of bedside and surgical devices and systems exist (eg, Aurix System/AutoloGel, SafeBlood, Magellan autotransfusion system, GPS II), and different devices and procedures can lead to variable concentrations of activated platelets and associated proteins.

This policy does not address fibrin sealants; fibrin glues and sealants are distinguished from PRP and are created from platelet-poor plasma and pooled donors or autologous platelet-poor plasma.

Platelet-rich plasma (PRP): Autologous platelet concentrate suspended in plasma prepared from centrifuged autologous blood, used as injection or adjunct to surgery to promote healing through growth factors.

Type	Number	Name	Effective Date
LCD	L38937	Platelet Rich Plasma
Article	A58609	Platelet Rich Plasma