CurrentCapital BluecrossPolicy MP 4.039

Orthopedic Applications of Platelet-Rich Plasma

This policy governs coverage of platelet-rich plasma (PRP) for orthopedic indications for Capital BlueCross products and programs, specifying that PRP use for these indications is investigational.

Policy Summary

PayerCapital Bluecross

PolicyOrthopedic Applications of Platelet-Rich Plasma

Policy CodePolicy MP 4.039

Change TypeNo material change

Effective Date8/1/2025

Next Review Date

Key ActionDo not bill PRP for orthopedic indications; procedures using codes P9020 or 0232T for these applications are investigational and may be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

all orthoInvestigational for

MP 4.039Policy ID

8/1/2025Effective

2Codes listed

multipleEvidence cited

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Coverage Criteria — Orthopedic PRP

Investigational — All orthopedic indications

Covered when ALL of the following are met

Investigational for orthopedic indications: Use of platelet-rich plasma is considered investigational for all orthopedic indications (including, but not limited to, primary injections for Achilles tendinopathy, lateral epicondylitis, plantar fasciitis, osteochondral lesions, osteoarthritis; and adjunctive use in procedures such as anterior cruciate ligament reconstruction, hip fracture repair, long-bone nonunion, patellar tendon repair, rotator cuff repair, spinal fusion, subacromial decompression, and total knee arthroplasty).

Policy statement — not covered due to investigational status

Evidence summaries — insufficient evidence coverage stance

Subacromial decompression with PRP: A single small randomized controlled trial reported no reduction in self‑ or physician‑assessed spinal instability scores with platelet‑rich plasma added to subacromial decompression, although there were improvements in subjective pain, pain medication use, and range of motion; larger trials are required and evidence is insufficient to determine improvement in net health outcome.

Evidence insufficient; not established as medically necessary

Total knee arthroplasty with PRP: Systematic reviews comparing platelet‑rich plasma with control in total knee arthroplasty reported no significant differences in range of motion, functional outcomes, or long‑term pain; evidence is insufficient to determine improvement in net health outcome.

Evidence insufficient; not established as medically necessary

Use of platelet-rich plasma (PRP) for all orthopedic indications is considered investigational and is not listed as medically necessary. This investigational determination explicitly applies to primary injectable uses (for example, Achilles tendinopathy, lateral epicondylitis, plantar fasciitis, osteochondral lesions, and osteoarthritis) and to adjunctive use with orthopedic surgeries (including but not limited to anterior cruciate ligament reconstruction, hip fracture repair, long-bone nonunion, patellar tendon repair, rotator cuff repair, spinal fusion, subacromial decompression surgery, and total knee arthroplasty).

PRP for orthopedic applications is identified as investigational and not covered when billed with the listed procedure codes. Specifically, services billed with P9020 or 0232T for orthopedic uses are considered investigational and therefore not covered under this policy.

PRP is designated as not medically necessary for orthopedic indications because current evidence is insufficient to demonstrate consistent, clinically meaningful improvement in net health outcomes. The policy identifies a range of primary and adjunctive orthopedic uses that remain investigational and not covered due to this lack of established benefit.

The available clinical evidence is inadequate to conclude that PRP improves net health outcomes for the orthopedic applications described. For example, a small randomized controlled trial in subacromial decompression showed some improvements in subjective pain, analgesic use, and range of motion but did not demonstrate reductions in key instability scores and requires confirmation in larger trials. Systematic reviews of PRP used with total knee arthroplasty found no significant differences in range of motion, functional outcomes, or long-term pain compared with control. Given these mixed and limited data, PRP for these orthopedic indications is considered investigational and is not covered; investigational coding (e.g., P9020, 0232T) is noted accordingly.

Procedure and Billing Codes

Investigational, therefore not covered when used for orthopedic applications: Procedure CodesHCPCSNot Covered

P9020	Procedure code listed as investigational for orthopedic applications
0232T	Procedure code listed as investigational for orthopedic applications

Provider Actions, Prior Authorization, and Claims

Note

Program / Product Applicability

This policy applies to certain Capital Blue Cross programs and products and may be subject to benefit variations. Refer to program-specific benefit documents for coverage details. FEP PPO members: see the FEP Medical Policy Manual at https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies.

Denial Risk

Investigational Determination

Use of platelet-rich plasma (PRP) for any orthopedic indication is considered investigational and may be denied. When billed for orthopedic applications, PRP procedures are not covered.

Background

Platelet-rich plasma (PRP) is an autologous concentrate derived from a patient’s own blood. It is prepared by centrifugation to concentrate platelets and associated growth factors in plasma and can be activated (for example, with thrombin and calcium) to release growth factors and form a fibrin-rich platelet gel. PRP has been investigated both as an injectable primary treatment for tendinopathies, plantar fasciitis, osteoarthritis, and osteochondral lesions and as an adjunct to various orthopedic surgical procedures; variability in preparation and application contributes to heterogeneity in study results.

Definitions

PRP (platelet‑rich plasma) definition — inv-17

DefinitionPlatelet‑rich plasma (PRP) — an autologous platelet concentrate suspended in plasma, prepared from centrifuged autologous blood and activated (e.g., with thrombin and calcium) to release growth factors and form a platelet gel.

Preparation methodPrepared from samples of centrifuged autologous blood; exposure to thrombin and calcium chloride degranulates platelets and releases growth factors.

Activation resultPolymerization of fibrin from fibrinogen creates a platelet gel intended to promote hemostasis and accelerate healing when used as an adjunct to surgery.

Clinical formsUsed either as an adjunct applied in the operating room (eg, with bone grafting or soft‑tissue repair) or injected directly into tissues for primary treatment of conditions such as tendinopathies and plantar fasciitis.

DistinctionPRP is distinct from fibrin glues/sealants (which are platelet‑poor plasma products typically derived from pooled donors); this review does not address fibrin sealants.