CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma) Coverage Policy

Coverage determination for autologous platelet-derived growth factors (PRP) for Blue Cross & Blue Shield of Rhode Island members, including distinctions for Commercial products and BlueCHiP for Medicare; affects providers submitting claims for PRP services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAutologous Platelet-Derived Growth Factors (Platelet-Rich Plasma) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 15, 2016

Next Review DateN/A

Key ActionVerify member-specific benefits and, for BlueCHiP for Medicare clinical trial services, submit claims with the Q0 modifier to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCommercial stance

Allowed in trialsBlueCHiP for Medicare

G0460, 0232TCodes cited

2019-03-05Last update

Coverage Determinations

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Coverage stance

Coverage determinations:

Commercial products: Autologous blood-derived preparations (e.g., platelet-rich plasma) are considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Evidence from small, mixed and limited trials; service considered not medically necessary for Commercial products.

BlueCHiP for Medicare: Autologous PRP is allowed only as part of a CMS‑approved clinical trial. Services rendered as part of such trials must be billed with the appropriate clinical trial modifier (Q0) and follow CMS/BlueCHiP for Medicare clinical trial billing procedures.

G0460 is allowable for BlueCHiP for Medicare only as part of a CMS‑approved study; 0232T is not covered.

The CPT code 0232T (Injection(s), platelet rich plasma, any site; including image guidance; harvesting and preparation when performed) is not covered for BlueCHiP for Medicare and is not medically necessary for Commercial products.

For Commercial products, autologous blood-derived preparations, including platelet-rich plasma (PRP), are considered not medically necessary because the available evidence is insufficient to determine the effects of PRP on health outcomes. The evidence base consists of small, mixed-quality trials with limited size and inconsistent results; therefore PRP services (including procedures reported with 0232T) are not covered for Commercial members.

Coding and Billing

Covered for BlueCHiP for Medicare (as part of CMS-approved clinical study)HCPCSCovered

G0460

Autologous platelet rich plasma for chronic wounds/ ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment

Not covered / not medically necessaryCPTNot Covered

0232T

Injection(s) , platelet rich plasma, any site; including image guidance; harvesting and preparation when performed

Required modifier for CMS-approved studiesModifier

Q0 (modifier)

Investigational clinical service provided in clinical research study that is in an approved research study

Provider Actions and Billing Rules

Prior Authorization

Prior authorization — Not applicable.

Note

Benefit Variation by Group

Benefit variation by group — refer to the Benefit Booklet / Evidence of Coverage (EOC) / Subscriber Agreement for member-specific benefit details and covered services. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement; those documents supersede this policy. For information on member-specific benefits and eligibility, contact the provider call center.

Documentation Required

Verify Member Benefits

Verify member benefits — verify member-specific benefits and eligibility before rendering services.

Billing Rule

Modifier Requirement for BlueCHiP for Medicare

Modifier requirement for BlueCHiP for Medicare — Claims for services provided as part of a CMS‑approved clinical study must be billed with the appropriate modifier (for example, Q0). BlueCHiP for Medicare claims filed without required modifiers may deny as not covered.

Background

Autologous platelet-rich plasma (PRP) is a concentrate of platelets prepared from the patient’s own blood. Platelets release growth factors (for example, platelet-derived growth factor, transforming growth factor, and vascular endothelial growth factor) when activated; activation (for example with thrombin and calcium chloride) can produce a platelet gel that has been used on wounds or as a surgical adjunct. PRP has been studied as an adjunct to wound healing and surgical procedures, but trials are generally small and of limited quality, and current evidence is insufficient to determine its effects on health outcomes for chronic or acute wounds.

Definitions

Platelet-rich plasma (PRP) — definition and preparation details

DefinitionAutologous platelet concentrate suspended in plasma prepared from centrifuged autologous blood (platelet-rich plasma, PRP).

Activation / PreparationExposure to thrombin and calcium chloride degranulates platelets, releasing growth factors and polymerizing fibrin to form a platelet gel used on wounds or as a surgical adjunct.

Primary biologic contentsPlatelets provide growth factors including platelet-derived growth factor (PDGF), transforming growth factors (TGF), vascular endothelial growth factor (VEGF), epidermal growth factor, fibroblast growth factors, and insulin-like growth factors.

Forms / usesPlatelet gel can be applied to wounds or used intraoperatively as an adjunct to promote hemostasis and accelerate healing in periodontal, reconstructive, and orthopedic procedures.

Distinction from fibrin gluesPRP is distinct from fibrin glues/sealants (which are made from platelet-poor plasma and commercial pooled donors); autologous fibrin sealants may also be produced from platelet-poor plasma.

Revision History

2016-11-15policy_effective

Policy effective date: coverage stance established for Commercial products (PRP considered not medically necessary) and BlueCHiP for Medicare (allowed only in CMS‑approved clinical trials).

2019-03-05last_reviewLatest

Policy last reviewed/updated on 2019-03-05 (document states policy updated 2019-03-05).