CurrentUnitedHealthcarePolicy MMP392.04

Platelet Rich Plasma Therapies

Medicare Advantage policy governing the use, coding, and Medicare-related coverage considerations for autologous platelet-rich plasma therapies for UnitedHealthcare Medicare Advantage plans and affiliated providers.

Policy Summary

PayerUnitedHealthcare

PolicyPlatelet Rich Plasma Therapies

Policy CodePolicy MMP392.04

Change TypeUpdated CMS documentsprior version archived

Effective DateNov 1, 2025

Next Review Date

Key ActionFollow applicable CMS NCDs/LCDs for PRP indications and obtain prior authorization when required by the member's Medicare Advantage plan or delegated manager.

SourceLink

POLICY UPDATE CHANGES

Updated list of CMS Medicare Coverage Database documents to reflect the most current information.

Previous policy version MMP392.03 archived.

CPT 0232T, G0460/G0465, P9020Key codes referenced

1NCDs referenced

MultipleLCDs/LCAs cross-referenced

11/01/2025Policy effective

Coverage Determinations and Criteria

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Application of CMS determinations

Coverage follows applicable CMS National Coverage Determinations (NCDs) and Local Coverage Determinations/Articles (LCDs/LCAs); where no CMS guidance exists, UnitedHealthcare internal criteria (see next section) apply.

CMS-guided coverage: When an NCD or an applicable LCD/LCA exists for a PRP indication (for example, NCD 270.3 for autologous PRP for chronic non‑healing diabetic wounds), coverage determinations shall follow those CMS documents.

See NCD 270.3 and the listed LCDs/LCAs in the CMS Related Documents table.

UnitedHealthcare internal criteria

When Medicare source materials do not provide specific coverage criteria or allow flexibility, UnitedHealthcare applies internal coverage criteria developed from evidence review and guidelines.

Internal criteria: UnitedHealthcare may apply internal medical necessity criteria for PRP indications not explicitly addressed by an NCD/LCD or when Medicare guidance permits coverage beyond specified indications. These internal criteria are based on evaluation of current clinical evidence and widely used treatment guidelines and are used to adjudicate Medicare Advantage claims consistent with member benefit documents.

UnitedHealthcare internal criteria supplement Medicare source materials and are applied where Medicare materials are absent or flexible; see policy text for details.

The following CPT code is identified as Non‑Covered for the described PRP procedure: CPT 0232T — “Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (Non‑Covered).” Coverage for PRP therapies is dependent on the applicable administration, indication, and adherence to Medicare guidance and member benefit terms; where a CMS NCD or applicable LCD/LCA governs an indication, those Medicare documents should be followed.

Certain HCPCS codes are explicitly described with mixed coverage language tied to specific indications and administration: HCPCS G0460 is listed as Non‑Covered for autologous PRP or other blood‑derived products when used for non‑diabetic chronic wounds/ulcers (description includes administration, dressings, phlebotomy, centrifugation or mixing, and other preparatory procedures, per treatment). HCPCS G0465 describes PRP for diabetic chronic wounds/ulcers when an FDA‑cleared device is used for that indication (coverage language differs from G0460). Additionally, HCPCS P9020 (Platelet rich plasma, each unit) is listed as Non‑Covered. Coverage depends on the specific indication, the device or preparation method used, and applicable Medicare and member benefit rules.

Coding and Billing Codes

CPT referencedCPTNot Covered

0232T

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

HCPCS referencedHCPCS

G0460	Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds/ulcers (includes administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) (Non-Covered)
G0465	Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication (includes administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)
P9020	Platelet rich plasma, each unit (Non-Covered)

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization May Be Required

Prior authorization or delegate-managed utilization requirements may apply per the member's Medicare Advantage plan or delegated manager. Verify prior authorization requirements before scheduling services to avoid denials or delays.

Member-specific plan and benefit documents determine prior authorization needs
For delegated plans, follow the delegate's prior authorization and utilization procedures

Note

Provider Operational Guidance

Providers must retain or have access to appropriate documentation to support coverage decisions and to help determine medical necessity, coding, and billing. Use this policy as a guide but confirm member-specific benefits and applicable laws. When in doubt, contact the customer service number on the member ID card or refer to the Administrative Guide.

This policy is informational and does not replace the member specific benefit plan document
Providers are responsible for independent clinical judgment and determining appropriate care

Documentation Required

Recordkeeping and Claims Submission

Providers are expected to retain complete documentation that supports coverage and medical necessity determinations and to submit accurate claims. Failure to provide requested documentation may result in denial, recoupment, or request for additional information.

Retain medical records, test results, and prior authorization correspondence for audit and review
Submit claims that accurately reflect the services rendered and the supporting documentation

Denial Risk

Documentation and Benefit Limits

Benefit coverage is determined by the member specific benefit plan document and applicable laws. Failure to follow member-specific benefit documents, applicable laws, or to retain required documentation may result in denials or recoupment. Inclusion of codes in this policy does not guarantee coverage or payment.

Member specific benefit plan document supersedes this policy in the event of a conflict
For questions about a specific member's coverage, call the customer service number on the member ID card or refer to the Administrative Guide

OpenPayer

Platelet Rich Plasma Therapies

Coverage Determinations and Criteria

Coding and Billing Codes

Provider Requirements and Operational Notes

Background

Definitions

Policy History and Revision Information