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Contractor Information

Contractor Name: National Government Services, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 13202 Contractor Type: MAC B

LCD Information

LCD ID Number: L38937 Status: A-Approved LCD Title: Platelet Rich Plasma Geographic Jurisdiction: New York - Downstate Other Jurisdictions Original Determination Effective Date: 08/01/2021 Original Determination Ending Date: Revision Effective Date: 02/10/2022 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, Section 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, Section 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, Section 10 General Exclusions from Coverage CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 270.3 Blood -Derived Products for Chronic Non-healing Wounds. Effective August 2, 2012, upon reconsideration, the Centers for Medicare and Medicaid Services (CMS) has determined that platelet-rich plasma (PRP) – an autologous blood-derived product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds and only when the conditions outlined in the NCD for CED are met. CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30A Physician’s Services CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.3.1 Mandatory ABN Uses Sorry, you need to login or register to view additional sections of this Medicare policy. *