Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-180
Topic: Autologous Platelet-Derived Growth Factors as a Primary Treatment for Wound Healing and Other Miscellaneous Conditions
Effective Date: September 11, 2006
Issued Date: February 4, 2008
Date Last Reviewed: 02/2008

General Policy Guidelines

Indications and Limitations of Coverage

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: 12/2007

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: 12/2007

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.

Procedure Codes

20999S9055    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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

View Previous Versions

[Version 002 of S-180]
[Version 001 of S-180]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.