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Contractor Information

Contractor Name: Noridian Healthcare Solutions, LLC - Full list of policies of this Medicare Contractor Contractor Number: 03102 Contractor Type: MAC B

LCD Information

LCD ID Number: L39060 Status: A-Approved LCD Title: Platelet Rich Plasma Injections for Non-Wound Injections Geographic Jurisdiction: Arizona 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 Sorry, you need to login or register to view additional sections of this Medicare policy. *