Chronic, Non-Healing Wounds
Autologous (a situation in which the donor and recipient are the same person) blood-derived preparations, S9055 (i.e., platelet-rich plasma), are considered investigational in the treatment of chronic non-healing wounds.  Examples of autologous blood-derived preparations include Autologel and SafeBlood.  A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed: 12/2009

Other Miscellaneous Conditions
The injection of Autologous blood-derived preparations, 0232T (i.e., injection platelet-rich plasma any tissue, including image guidance, harvesting and preparation when performed), is considered investigational as a primary procedure for other miscellaneous conditions including, but not limited to, epicondylitis (i.e., tennis elbow), plantar fasciitis or Dupuytren's contracture (abnormal thickening of tough tissue in the palm and fingers that can cause the fingers to curl).  A participating, preferred, or network provider can bill the member for the denied service.

NOTE:

Code 20926 [Tissue grafts, other (eg, paratenon, fat, dermis)] should not be reported for injection of autologous blood-derived preparations.

Date Last Reviewed: 12/2009

Description

Chronic, Non-Healing Wounds
Autologous Platelet-Derived Growth Factors (PDGF) have also been investigated as wound healing products. Blood is donated by the patient and centrifuged to produce a concentrate high in both platelets and plasma proteins. Individual growth factors are not identified or separated during this process. Additives are used to change the consistency of the product.  Exposure to a solution of thrombin and calcium chloride results in the polymerization of fibrin from fibrinogen, creating a platelet gel.  The platelet gel can then be applied to wounds. Activated platelets then degranulate, releasing the various growth factors into the wound.

Other Miscellaneous Conditions
Autologous blood injections are autologous blood mixed with lidocaine HCL or bupivacaine HCL and injected into various anatomical sites to provide the necessary cellular and humoral mediators to induce healing for conditions such as epicondylitis, plantar fasciitis and Dupuytren’s contracture, etc.

Platelet-rich plasma should be distinguished from fibrin glues or sealants, which have been used for many years as a surgical adjunct to promote local hemostasis at incision sites. Fibrin glue is created from platelet-poor plasma and consists primarily of fibrinogen. Commercial fibrin glues are created from pooled homologous human donors. Tissel (Baxter) and Hemaseal are examples of commercially available fibrin sealants. Autologous fibrin sealants can be created from platelet-poor plasma. This policy does not address the use of fibrin sealants.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition.

Efficacy of Concentrated Autologous Platelet-Derived Growth Factors in  Chronic Lower-Extremity Wounds, Journal of the American Podiatric Medical Association, 2006.

The Healing Effects of Autologous Platelet Gel on Acute Human Skin Wounds, Archives of Facial Plastic Surgery, May-June 2007.

A Prospective, Randomized, Controlled Trial of Autologous Platelet-Rich Plasma Gel for The Treatment of Diabetic Foot Ulcers, Ostomy wound Management, June 2006

MPRM 2.01.16

Martinez-Zapata MJ, Marti-Carvajal A, Sola I, Bolibar I, Angel Expoisito J, Rodriguez L, Garcia J.  Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration:  a systematic review.  Transfusion.  2009 Jan;49(1):44-56. Epub 2008 Oct 14.

Cervelli V, Gentile P, Grimaldi M.  Regenerative surgery: use of fat grafting combined with platelet-rich plasma for chronic lower-extremity ulcers.  Aesthetic Plast Surg.  2009 May;33(3):340-5.  Epub 2009 Jan 21.

Hom David B, MD, Linzie Bradley M, MD, Huang Trevor C, PhD.  The healing effects of autologous platelet gel on acute human skin wounds.  Arch Facial Plast Surg. 2007;9:174-183.

Dougherty EJ.  An evidence-based model comparing the cost-effectiveness of platelet-rich plasma gel to alternative therapies for patients with nonhealing diabetic foot ulcers.  Adv Skin Wound Care.  2008 Dec;21(12):568-75.

Whitlow J, Shackelford A, Sievert A, Sistino J.   Barriers to the acceptance and use of autologous platelet gel.  Perfusion.  2008 Sep;23(5):283-9.

Mishra Allan, MD, Woodall James, Jr., MD, Vieira, PA-C.  Treatment of tendon and muscle using platelet-rich plasma.  Clin Sports Med 28 (2009) 113-125.

Buchwald D, Kaltschmidt C, Haardt H, Laczkovics A, Reber D.  Autologous platelet gel fails to show beneficial effects on wound healing after saphenectomy in CABG patients.  J Extra Corpor Technol.  2008 Sep;40(3):196-202.

Sanchez M, Anitua E, Orive G, Mujika I, Andia I.  Platelet-rich therapies in the treatment of orthopaedic sport injuries.  Sports Med. 2009;39(5):345-54.

De Mos Marieke, MD, Van Der Windt Anna E, MSc, Jahr Holger, PhD, Van Schie Hams T.M., DVM, PhD et al. Can platelet-rich plasma enhance tendon repair?  A cell culture study.  AJSM PreView March 7, 2008.

Mishra Allan, MD, Pavelko Terri, PAC, PT.  Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. AJSM 2006 Nov;34(11):1774-8.

Sampson Steven, Gerhardt Michael, Mandelbaum Bert.  Platelet rich plasma injection grafts for musculoskeletal injuries:  a review. Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):165-74