Autologus platelet rich plasma (PRP) injections

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is not applicable for autologous platelet rich plasma (PRP) injections because it is considered investigational/experimental.

The provider and facility will be liable for payment unless:

• The provider notifies the member that a specific service has been determined by CoOportunity Health to be investigational/experimental; and
• The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
• The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Platelet derived blood products are not covered because there is not scientific evidence to prove their effectiveness. These non covered products include but are not limited to:

1. Autologous platelet rich plasma injections
2. Autologous platelet gel
3. Autologous platelet derived growth factors (e.g., Procuren)

Autologous platelet rich blood products are removed from the patient’s own blood through a process called therapeutic apheresis. They have been studied for use in clinical applications such as an adjunct during surgery or for management of chronic wounds.

Therapeutic apheresis -The patient’s blood is gathered similarly to giving a blood donation. The blood is separated and the platelets are collected for use in the planned treatment.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

0232T - Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and
preparation when performed
P9020 - Platelet rich plasma, each unit
S0157 - Becaplermin gel 0.01%, 0.5 gm (recombinant platelet-derived growth factor)
S9055 - Procuren or other growth factor preparation to promote wound healing

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.