Medical Policy
Platelet-rich Plasma Injections
Effective Date: July 1, 2016
Subject: Platelet-rich Plasma Injections
Overview: Platelet-rich plasma injection has been proposed as a treatment for tendonopathies (elbow, knee,
shoulder and heel) and other musculoskeletal injuries.
Policy and Coverage Criteria:
Harvard Pilgrim does NOT cover platelet-rich plasma injections; it is considered experimental/investigational and
unproven.
Exclusions: N/A
Supporting Information:
1. Technology Assessment:
Most often used for the treatment of tendon and ligament injuries, platelet-rich plasma (PRP) is prepared from
whole blood collected from the patient. A small volume of the patient’s blood is obtained using a standard
venipuncture or blood draw procedure. Autologous whole blood is mixed with citrate phosphate dextrose to
prevent coagulation. The rationale for using autologous PRP to stimulate healing is that platelets are one of the
predominant regulatory cells involved in the repair process following tissue injury. At sites of tissue injury,
platelets become activated and adhere, where they promote healing by releasing potent locally acting growth
factors that stimulate a connective tissue response, causing cell migration and division, synthesis of extracellular
matrix proteins, and formation of new capillaries.
2. Literature Review:
The 2014 NICE Guidance Recommendations state the evidence on efficacy of platelet-rich plasma injections to
treat osteoarthritis is inadequate in quality. The 2013 NICE Guidance Recommendations for tendinopathy also
state the evidence on efficacy remains inadequate. A 2012 assessment by NICE evaluated the use of patientderived blood and platelets to treat painful tendonopathies. The authors found differences in postoperative
rehabilitation protocol and duration also variation in the use of the procedure. Most studies evaluated PRP use in
tendinopathy of the elbow, with some variation in injection technique. Ultimately, the authors found the relative
benefits of PRP and follow up physical therapy to be difficult to determine.
A review by Jiang and Wang (2013) assessed the use of PRP for the treatment of tendinopathy. They discuss the
positive rationales for using PRP, but note “the efficacy of PRP treatment in enhancing the recovery of
tendinopathic tendons has not been conclusively or consistently demonstrated in clinical trials.” The authors call
for more studies to investigate and better define the precise effects of PRP treatment. Stance et al. (2012) also
reviewed literature on the role of PRP in tissue healing and treatment of sport-related injuries. Their assessment
also called for further studies to better define the efficacy and limitations of PRP. Lee (2013) reviewed literature
on the biology of PRP, how it may promote healing, and common applications of the therapy. The review found
the treatment to be promising for common musculoskeletal injuries, but that further trials are needed to establish
effectiveness, indications and protocols for its use.
A 2010 IOC consensus paper on the use of platelet-rich plasma in sports medicine reviewed evidence evaluating
PRP for a number of injuries and conditions. The reviewers noted, “It is difficult to formulate indications for the
use of PRP on tendon injuries in a clinical setting based on the available scientific evidence. In a recent review
investigating the use of autologous blood products, including PRP, in the management of tendinopathy, only
three studies on PRP had adequate methodology. All these three studies considered to have adequate
methodology did not demonstrate any significant benefit from the injection of PRP into injured tendons.
In summary, there is a lack of well-designed studies to support the use of PRP in clinical settings in the
management of tendon injuries. More research on basic science and the clinical application of PRP needs to be
undertaken before there is any comprehensive recommendation for PRP administration in injured human tendons.
For each individual athlete and circumstance, a risk/benefit analysis should be performed before embarking on
this as yet scientifically unproven therapeutic modality.” The authors found a limited amount of basic science
research on the influence of PRP on the inflammation and repair of connective tissue and skeletal muscle. There
is a large amount of variability in PRP preparation and platelet concentration. The lack of standardization makes
it difficult to establish an appropriate treatment standard.
A 2011 review by Nguyen et al. critically looked at the literature pertaining to the therapeutic use of autologous
PRP. The authors reviewed studies discussing the use of PRP for a number of conditions and injuries. The
authors also discuss their own experiences in using PRP to treat patients in their practices. Their
recommendations appear in the review. However, they note that scientific literature evaluating PRP is still in its
infancy and there is limited data supporting the treatment as standard of care. Nguyen et al. concluded PRP to
be a promising treatment option, but further RCTs are needed to study the various clinical musculoskeletal
conditions.
Everts et al. (2008) reported on Double-blind RCT to evaluate PRP as an adjunct to open subacromial
decompression surgery for stage II shoulder impingement. 10 men and 5 women underwent the procedure with
PRP injected into the subacromial and intracapsular spaces at the end of surgery. 15 patients were in the
control. Measured outcomes included pain VAS, ROM, and SIS. Differences between the PRP and control groups
in pain medication use were significant at weeks 1, 2, and 4. There was no difference in self-assessed shoulder
instability. The researchers concluded PRP accelerates healing.
A study by Castricini et al. (2011) had different results. 43 patients underwent rotator cuff repair and received
PRP injection during surgery. 45 patients underwent the same surgery without PRP. Measured outcomes
included MRI score, shoulder pain, ADL, ROM and strength. There were no significant differences between the
two groups in the measured outcomes. The researchers concluded PRP did not improve outcomes.
de Vos et al. (2011) assessed whether PRP injection leads to enhanced tendon structure and neovascularization
in chronic midportion Achilles tendinopathy. 54 patients had their tendon structure evaluated using
ultrsonographic tissue characterization. 27 patients underwent PRP injection and 27 received a placebo. There
were no significant differences between the two groups at 6 weeks. de Vos et al. concluded PRP does not
contribute to increased tendon structure or alter the degrees of neovascularization compared to placebo.
In a 2006 study, Mishra and Pavelko reported on the results of a cohort study of 140 patients with epicondylar
elbow pain. 20 of the 140 patients had persistent pain for a mean of 15 months after conservative treatment
interventions. 15 patients received a single percutaneous injection of platelet-rich plasma. 5 patients (control)
received an injection of bupivacaine. 8 weeks after treatment, the platelet-rich injection group noted 60%
improvement in their VAS scores. The control group showed a 16% improvement. After 8 weeks 3 of the 5
control patients withdrew or sought other treatment. At 6 months, the active group noted an 81% improvement
in VAS scores. At final follow-up (mean 25.6 months; range 12-38 months), the platelet-rich plasma patients
reported 93% reduction in pain compared with before the treatment. Based on these results the authors
concluded that the platelet-rich plasma injection significantly reduced pain in the treated patients but that further
evaluation of the novel treatment is warranted.
Peerbooms et al. (2010) reported the results of a study evaluating the effectiveness of PRP compared with
corticosteroid injections in patients with chronic lateral epicondylitis. 51 patients were in the PRP group and 49 in
the steroid group. Measured outcomes were VAS and DASH outcome measure scores. Successful treatment was
defined as more than a 25% reduction in visual analog score or DASH score without a reintervention after one
year. VAS scores shoed 49% of the steroid patients were successful and 73% of the PRP patients were
successful. These improvements were significantly different. Results also showed the steroid group was better
initially and then declined, whereas the PRP group progressively improved. The results led the researchers to
conclude PRP treatment in patients with chronic lateral epicondylitis reduces pain and increases function. They
also noted future decisions for application of PRP for lateral epicondylitis should be confirmed by further followup.
A number of studies have evaluated PRP as an adjunct to ACL repair (Orrego et al. 2009; Silva and Sampaio,
2009; Figueroa et al., 2010; Radice et al, 2010; Vogrin et al. 2010). Results were mixed. All investigations had
small sample sizes. Some researchers concluded PRP accelerated healing, post-repair. Others concluded it did
not improve outcomes.
3. Professional/Governmental Agencies:
CMS: No National Coverage Determination addressing platelet-rich plasma injections
Codes:
CPT:
38206 – Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
86999 – Unlisted transfusion medicine procedure
96379 – Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion
References:
1. Hayes, Inc. Medical Technology Directory. Platelet-Rich Plasma for Ligament and Tendon Injuries. Lansdale,
PA: Hayes, Inc. December 24, 2012.
2. Engebresten, L., Steffen, K., Alsousou, J., et al. IOC consensus paper on the use of platelet-rich plasma in
sports medicine. Br J Sports Med. 2010; 44: 1072-1081.
3. Nguyen, RT., Borg-Stein, J., McInnis, K. Applications of platelet-rich plasma in musculoskeletal and sports
medicine: an evidence-based approach. PM R. 2011; 3(3): 226-50.
4. Mishra, A., Pavelko, T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J
Sports Med. 2006; 34(11): 1774-8.
5. Orrego, M., Larrain, C., Rosales, J., et al. Effects of platelet concentrate and a bone plug on the healing of
hamstring tendons in a bone tunnel. Arthroscopy. 2008; 24(12): 1373-1380.
6. Everts, PA., Devilee, RJ., Brown Mahoney, C., et al. Exogenous application of platelet-leukocyte gel during
open subacromial decompression contributes to improved patient outcome. A Prospective randomized
double-blind study. Eur Surg Res. 2008; 40(2): 203-10.
7. Castricini, R., Longo, UG., De Benedetto, M., et al. Platelet-rich plasma augmentation for arthroscopic rotator
cuff repair: a randomized controlled trial. Am J Sports Med. 2011; 39(2): 258-65.
8. de Vos, RJ., Weir, A., Tol, JL., et al. No effects of PRP on ultraosonographic tendon structure and
neovascularization in chronic midportion Achilles tendinopathy. Br J Sports Med. 2011; 45(5): 387-92.
9. Peerbooms, JC., Sluimer, J., Bruijn, DJ., Gosens, T. Positive effect of an autologous platelet concentrate in
later apicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid
injection with a 1-year follow up. Am J Sports Med. 2010; 38(2): 255-62.
10. Silva, A., Sampaio, R. Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing?
Knee Surg Sports Traumatol Arthrosc. 2009; 17(6): 676-682.
11. Figueroa, D., Melean, P., Calvo, R., et al. Magnetic resonance imaging evaluation of the integration and
maturation of semiendinosus-gracilis graft in anterior cruciate ligament reconstruction using autologous
platelet concentrate. Arthroscopy. 2010; 26(10): 1318-1325.
12. Radice, F., Yanez, R., Gutierrez, V., Rosales, J., et al. Comparison of magnetic resonance imaging findings in
anterior cruciate ligament grafts with and without autologous platelet-derived growth factors. Arthroscopy.
2010; 26(1): 50-57.
13. Vogrin, M., Rupreht, M., Cmjac, A., et al. The effect of platelet-derived growth factors on knee stability after
anterior cruciate ligament reconstruction: a prospective randomized clinical study. Wien Klin Wochenschr.
2010; 122(Suppl 2): 91-95.
14. Jiang, D., Wang, JH. Tendinopathy and its treatment with platelet-rich plasma (PRP). Histol Histopathol.
2013; 28(12): 1537-1546.
15. Stanco, D., Vigano, M., Croiset-SJ., De Girolamo, L. Applications and limits of platelet-rich plasma in sports
related injuries. J Biol Homeost Agents. 2012; 26(2 Suppl 1): 53S-61S.
16. Lee, KS. Platelet-rich plasma injection. Semin Musculoskelet Radiol. 2013; 17(1): 91-8NICE, UK.
Interventional procedure guidance for platelet-rich plasma injections for osteoarthritis of the knee. May 2014.
http://www.nice.org.uk/guidance/ipg491