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LCD ID Number: L39060 Status: A-Approved
LCD Title: Platelet Rich Plasma Injections for Non-Wound Injections
Geographic Jurisdiction: South Dakota Other Jurisdictions
Original Determination Effective Date:
01/23/2022
Original Determination Ending Date:
Revision Effective Date:
01/23/2022
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.1 Effective August 2, 2012, updated 4/13/21, the Centers for Medicare and Medicaid Services (CMS) has determined that platelet-rich plasma (PRP) – an autologous blood-derived product, will be covered for the treatment of chronic non-healing diabetic wounds under section 1862(a)(1)(A) for a duration of 20 weeks, when prepared by devices who FDA cleared. Indications include the management of exuding cutaneous wounds, such as diabetic ulcers.
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §30A Physician’s Services
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, §50.3.1 Mandatory ABN Uses
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