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: 12/2005

Other Miscellaneous Conditions
The injection of Autologous blood-derived preparations, 20999 (i.e., platelet-rich plasma), is considered investigational as a primary procedure for other miscellaneous conditions including, but not limited to, epicondylitis (i.e., tennis elbow), plantar faciitis 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.

Date Last Reviewed: 12/2005

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.

MPRM 2.01.16