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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 10111 Contractor Type: MAC A

LCD Information

LCD ID Number: L38745 Status: A-Approved LCD Title: Platelet Rich Plasma Geographic Jurisdiction: Alabama Other Jurisdictions Original Determination Effective Date: 02/07/2021 Original Determination Ending Date: Revision Effective Date: 09/12/2024 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(1)(D) addresses services that are determined to be investigational or experimental. CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §10 General Exclusions from Coverage CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §270.3 Blood -Derived Products for Chronic Non-healing Wounds. CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §30A. Physician’s Services Sorry, you need to login or register to view additional sections of this Medicare policy. *