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Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions Form

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Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

Indications

(1) Is the request for Autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds? 
(2) Is the request for All other indications? 
(3) Is the request for Use of platelet-rich plasma (ie, autologous blood-derived preparations)? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|01|2026 POLICY LAST REVIEWED: 02|18|2026 OVERVIEW The use of blood-derived growth factors, including recombinant platelet-derived growth factors (PDGFs) and platelet-rich plasma (PRP), has been suggested as a treatment for wounds or other miscellaneous non- orthopedic conditions, including but not limited to, diabetic ulcers, pressure ulcers, venous stasis ulcers, and surgical and traumatic wounds This policy is only applicable to autologous platelet-rich plasma (PRP). MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION
Not applicable POLICY STATEMENT Medicare Advantage Plans Autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds is covered when filed with a covered diagnosis (See coding section). All other indications are not covered as the evidence is insufficient to determine the effects of the technology on health outcomes. Commercial Products Use of platelet-rich plasma (ie, autologous blood-derived preparations) is considered not medically necessary for the treatment of acute or chronic wounds, including surgical wounds and nonhealing ulcers as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary among groups. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for services not medically necessary.
BACKGROUND A variety of growth factors have been found to play a role in wound healing, including platelet-derived growth factor (PDGF), epidermal growth factor, fibroblast growth factors, transforming growth factors, and insulin-like growth factors. Autologous platelets are a rich source of PDGF, transforming growth factors (that function as a mitogen for fibroblasts, smooth muscle cells, and osteoblasts), and vascular endothelial growth factors. Autologous platelet concentrate suspended in plasma, also known as platelet-rich plasma (PRP), can be prepared from samples of centrifuged autologous blood. Exposure to a solution of thrombin and calcium chloride degranulates platelets, releasing various growth factors, and results in the polymerization of fibrin from fibrinogen, creating a platelet gel. The platelet gel can then be applied to wounds or may be used as an adjunct to surgery to promote hemostasis and accelerate healing. In the operating room setting, PRP has been investigated as an adjunct to a variety of periodontal, reconstructive, and orthopedic procedures. For example, bone morphogenetic proteins are a type of transforming growth factor, and thus PRP has been used in conjunction with bone-replacement grafting (using either autologous grafts or bovine-derived xenograft) in periodontal and maxillofacial surgeries.
Medical Coverage Policy | Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

PRP is distinguished from fibrin glues or sealants, which have been used for many years as a surgical adjunct to promote local hemostasis at incision sites. Fibrin glue is created from platelet-poor plasma and consists primarily of fibrinogen. Commercial fibrin glues are created from pooled homologous human donors; Tisseel® (Baxter International) and Hemaseel® (Haemacure Corp.) are examples of commercially available fibrin sealants. Autologous fibrin sealants can also be created from platelet-poor plasma.

For individuals who have chronic wounds who receive platelet-rich plasma (PRP), the evidence includes meta-analyses of a number of small controlled trials. Relevant outcomes are symptoms, change in disease status, morbid events, quality of life, and treatment-related morbidity. In meta-analyses of individuals with lower extremity diabetic ulcers, PRP demonstrated an improvement over the control groups in complete wound closure and healing time, but moderate to high risk of bias and imprecision preclude drawing conclusions on other important outcomes such as recurrence, infection, amputation, and quality of life. In individuals with venous ulcers, PRP did not demonstrate an improvement over the control groups in complete wound closure, recurrence, wound infection or quality of life, although imprecision likely precluded identifying differences on these outcomes. In individuals with pressure ulcers, although PRP reduced wound size, other important outcomes such as complete wound closure were not measured. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have acute surgical or traumatic wounds who receive PRP, the evidence includes systematic reviews and a number of small controlled trials. Relevant outcomes are symptoms, change in disease status, morbid events, quality of life, and treatment-related morbidity. Current results of trials using PRP are mixed and the studies are limited in both size and quality. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Medicare Advantage Plans In April 2021, CMS published an updated decision memo following the fourth reconsideration of the national coverage analysis stating that CMS will "cover autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds under section 1862(a)(1)(A) of the Social Security Act (the Act) for a duration of 20 weeks, when prepared by devices whose FDA cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers. Coverage of autologous PRP for the treatment of chronic non-healing diabetic wounds beyond 20 weeks will be determined by local Medicare Administrative Contractors (MACs). Coverage of autologous PRP for the treatment of all other chronic non-healing wounds will be determined by local Medicare Administrative Contractors (MACs) under section 1862(a)(1)(A) of the Act CODING Medicare Advantage Plans and Commercial Products The following code is covered when filed with a covered diagnosis for Medicare Advantage Plans and not medically necessary for Commercial Products. G0465 Autologous platelet rich plasma (PRP) for diabetic chronic wounds/ulcers, using an FDA-cleared device (includes administration, dressings, phlebotomy, centrifugation, and all other preparatory procedures, per treatment)

ICD-10-CM Diagnosis List

The following code is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products as it is used for non-diabetic chronic wounds/ulcers G0460 Autologous platelet rich plasma for non-diabetic chronic wounds/ulcers, including
phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment

RELATED POLICIES None

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PUBLISHED Provider Update, April 2026 Provider Update, April/December 2025 Provider Update, April 2024 Provider Update, December 2023 Provider Update, December 2022

REFERENCES:

  1. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD), Blood- Derived Products for Chronic Non-Healing Wounds (270.3)
  2. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD), Platelet Rich Plasma Injections for Non-Wound Injections (L39058)
  3. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) Article, Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58788)
  4. U.S. Food and Drug Administration. Guidance for Industry: Chronic Cutaneous Ulcer and Burn Wounds – Developing Products for Treatment. Rockville, MD: Food and Drug Administration; 2006 June.
  5. U.S. Food and Drug Administration (FDA). Tissue and Tissue Products. 2016; http://www.fda.gov/BiologicsBloodVaccines/TissueTissueProducts/. Accessed December 13, 2024.
  6. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Becaplermin for wound healing. TEC Assessments. 1999;Volume 14:Tab 5.
  7. Crovetti G, Martinelli G, Issi M, et al. Platelet gel for healing cutaneous chronic wounds. Transfus Apher Sci. Apr 2004;30(2): 145-51. PMID 15062754
  8. Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg. Nov 2004; 114(6): 1502-8. PMID 15509939
  9. Kevy SV, Jacobson MS. Comparison of methods for point of care preparation of autologous platelet gel. J Extra Corpor Technol. Mar 2004; 36(1): 28-35. PMID 15095838
  10. Castillo TN, Pouliot MA, Kim HJ, et al. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med. Feb 2011; 39(2): 266-71. PMID 21051428
  11. Mazzucco L, Balbo V, Cattana E, et al. Not every PRP-gel is born equal. Evaluation of growth factor availability for tissues through four PRP-gel preparations: Fibrinet, RegenPRP-Kit, Plateltex and one manual procedure. Vox Sang. Aug 2009;97(2): 110-8. PMID 19392780
  12. Zhao XH, Gu HF, Xu ZR, et al. Efficacy of topical recombinant human platelet-derived growth factor for treatment of diabetic lower-extremity ulcers: Systematic review and meta-analysis. Metabolism. Oct 2014; 63(10): 1304-13. PMID25060693
  13. Sridharan K, Sivaramakrishnan G. Growth factors for diabetic foot ulcers: mixed treatment comparison analysis of randomized clinical trials. Br J Clin Pharmacol. Mar 2018; 84(3): 434-444. PMID 29148070
  14. Margolis DJ, Bartus C, Hoffstad O, et al. Effectiveness of recombinant human platelet-derived growth factor for the treatment of diabetic neuropathic foot ulcers. Wound Repair Regen. 2005; 13(6): 531-6. PMID 16283867
  15. Rees RS, Robson MC, Smiell JM, et al. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999; 7(3): 141-7. PMID 10417749
  16. Senet P, Vicaut E, Beneton N, et al. Topical treatment of hypertensive leg ulcers with platelet-derived growth factor-BB: a randomized controlled trial. Arch Dermatol. Aug 2011; 147(8): 926-30. PMID 21482863
  17. Freedman BM, Oplinger EH, Freedman IS. Topical becaplermin improves outcomes in work related fingertip injuries. J Trauma. Oct 2005; 59(4): 965-8. PMID 16374289
  18. Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, et al. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev. May 25 2016; 2016(5): CD006899. PMID 27223580
  19. Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, et al. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev. Oct 17 2012; 10: CD006899. PMID 23076929

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  1. Carter MJ, Fylling CP, Parnell LK. Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis. Eplasty. 2011; 11: e38. PMID 22028946
  2. Picard F, Hersant B, Bosc R, et al. The growing evidence for the use of platelet-rich plasma on diabetic chronic wounds: A review and a proposal for a new standard care. Wound Repair Regen. Sep 2015; 23(5): 638-43. PMID 26019054
  3. Del Pino-Sedeño T, Trujillo-Martín MM, Andia I, et al. Platelet-rich plasma for the treatment of diabetic foot ulcers: A meta-analysis. Wound Repair Regen. Mar 2019; 27(2): 170-182. PMID 30575212
  4. Li Y, Gao Y, Gao Y, et al. Autologous platelet-rich gel treatment for diabetic chronic cutaneous ulcers: A meta-analysis of randomized controlled trials. J Diabetes. May 2019; 11(5): 359-369. PMID 30182534
  5. Qu W, Wang Z, Hunt C, Morrow AS, Urtecho M, Amin M, Shah S, Hasan B, Abd-Rabu R, Ashmore Z, Kubrova E, Prokop LJ, Murad MH. Platelet-Rich Plasma for Wound Care in the Medicare Population. Technology Assessment Program Project ID 040-353-492. (Prepared by the Mayo Clinic Evidence- based Practice Center under Contract No.HHSA290201500013I.) Rockville, MD: Agency for Healthcare Research and Quality. https://pubmed.ncbi.nlm.nih.gov/34978778/. Accessed November 25, 2025.
  6. Deng J, Yang M, Zhang X, et al. Efficacy and safety of autologous platelet-rich plasma for diabetic foot ulcer healing: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. May 19 2023; 18(1): 370. PMID37202812
  7. Platini H, Adammayanti KA, Maulana S, et al. The Potential of Autologous Platelet-Rich Plasma Gel for Diabetic Foot Ulcer Care Among Older Adults: A Systematic Review and Meta-Analysis. Ther Clin Risk Manag. 2024; 20: 21-37. PMID38288358
  8. Hu X, Meng H, Liang J, et al. Comparison of the efficacy of 12 interventions in the treatment of diabetic foot ulcers: a network meta-analysis. Peer J. 2025; 13: e19809. PMID 40821981
  9. Tian J, Yao G, Tian T, et al. Comparison of the efficacy and safety of different growth factors in the treatment of diabetic foot ulcers: an updated network meta-analysis. Front Endocrinol (Lausanne). 2025; 16: 1614597. PMID 40636711
  10. Martínez-Zapata MJ, Martí-Carvajal A, Solà I, et al. Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration: a systematic review. Transfusion. Jan 2009; 49(1): 44-56. PMID 18954394
  11. Qu S, Hu Z, Zhang Y, et al. Clinical Studies on Platelet-Rich Plasma Therapy for Chronic Cutaneous Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Adv Wound Care (New Rochelle). Feb 2022; 11(2): 56-69. PMID 33607926
  12. Abhirami C, Vignesh KA, Sivasubramanian V. Assessing the effect of platelet rich plasma(prp) among patients with chronic diabetic foot ulcers attending dermatology opd from a private medical institute in kancheepuram district, tamilnadu. Eur J Mol Clin Med. (2023) 10:263043.
  13. Ahmed M, Reffat SA, Hassan A, et al. Platelet-Rich Plasma for the Treatment of Clean Diabetic Foot Ulcers. Ann VascSurg. Jan 2017; 38: 206-211. PMID 27522981
  14. Alamdari DH, Asadi M, Rahim AN, et al. Efficacy and Safety of Pleurodesis Using Platelet-Rich Plasma and Fibrin Glue in Management of Postoperative Chylothorax After Esophagectomy. World J Surg. Apr 2018; 42(4): 1046-1055. PMID28986682
  15. Chen HY, Chen CX, Liang Y, Wang J. Efficacy of autologous platelet rich gel in the treatment of refractory diabetic foot. Chin J New Clin Med. 2008; 17:1-2.
  16. Driver VR, Hanft J, Fylling CP, et al. A prospective, randomized, controlled trial of autologous platelet- rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage. Jun 2006; 52(6): 68- 70, 72, 74 passim. PMID 16799184
  17. Elsaid A, El-Said M, Emile S, et al. Randomized Controlled Trial on Autologous Platelet-Rich Plasma Versus Saline Dressing in Treatment of Non-healing Diabetic Foot Ulcers. World J Surg. Apr 2020; 44(4): 1294-1301. PMID 31811339
  18. Friese G, Herten M, Scherbaum WA. The use of autologous platelet concentrate activated by autologous thrombin (APC+)is effective and safe in the treatment of chronic diabetic foot ulcers-a randomized controlled trial. In: eds. Proceedings of the Fifth International Symposium on the Diabetic Foot, May September 12, 2007, Noordwijkerhout, The Netherlands.2007.

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  1. Game F, Jeffcoate W, Tarnow L, et al. LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomised controlled trial. Lancet Diabetes Endocrinol. Nov 2018;6(11): 870-878. PMID 30243803
  2. Gude W, Hagan D, Abood F, et al. Aurix Gel Is an Effective Intervention for Chronic Diabetic Foot Ulcers: A Pragmatic Randomized Controlled Trial. Adv Skin Wound Care. Sep 2019; 32(9): 416-426. PMID 31436621
  3. Goda A, Metwally M, Ewada A, et al. Platelet-rich plasma for the treatment of diabetic foot ulcer: a randomized, double-blind study. Egyptian Journal of Surgery. Mar 2018; 37 (178-184).
  4. Gowsick et al. (2023).Gowsick S, Balaji D, Arul, Unnikrishnan ES, Manish R. Comparison of the efficacy of autologous platelet-rich plasma and saline dressing in healing of diabetic foot ulcer- a randomised control study. Journal of Clinical and Diagnostic Research. 2023;17:PC17PC22. doi: 10.7860/JCDR/2023/60861.17987
  5. Gupta A, Channaveera C, Sethi S, et al. Efficacy of Intralesional Platelet-Rich Plasma in Diabetic Foot Ulcer. J Am Podiatr Med Assoc. May 01 2021; 111(3). PMID 33231614
  6. Habeeb T, AA E, H M. Platelet-rich plasma (PRP) bio-stimulant gel dressing in treating chronic non- healing leg and foot ulcers; cost and effectiveness. Randomized Controlled Clinical Trial. 2021.
  7. Helmy Y, Farouk N, Ali Dahy A, et al. Objective assessment of Platelet-Rich Plasma (PRP) potentiality in the treatment of Chronic leg Ulcer: RCT on 80 patients with Venous ulcer. J Cosmet Dermatol. Oct 2021; 20(10): 3257-3263. PMID33880860
  8. Hossam EM, Alserr AHK, Antonopoulos CN, et al. Autologous Platelet Rich Plasma Promotes the Healing of Non-Ischemic Diabetic Foot Ulcers. A Randomized Controlled Trial. Ann Vasc Surg. May 2022; 82: 165-171. PMID 34896242
  9. Jeong SH, Han SK, Kim WK. Treatment of diabetic foot ulcers using a blood bank platelet concentrate. Plast Reconstr Surg. Mar 2010; 125(3): 944-52. PMID 20195121
  10. Kamineni R, Tupkar G. Efficacy of platelet rich plasma dressing versus normal saline dressing in the management of diabetic foot ulcers. Int J Pharm Clin Res. (2023) 15:23742.
  11. Kakagia DD, Kazakos KJ, Xarchas KC, et al. Synergistic action of protease-modulating matrix and autologous growth factors in healing of diabetic foot ulcers. A prospective randomized trial. J Diabetes Complications. 2007; 21(6): 387-91. PMID 17967712
  12. Karimi R, Afshar M, Salimian M, et al. The effect of platelet rich plasma dressing on healing diabetic foot ulcers. Nurs Midwifery Stud. 2016;5(3):e30314.
  13. Li L, Wang C, Wang Y, He LP, Yang YZ, Chen LH, et al. Impact of topical application of autologous platelet-rich gel on medical expenditure and length of stay in hospitals in diabetic patients with refractory cutaneous ulcers. Sichuan Da Xue Xue Bao Yi Xue Ban. 2012;43(5):7625
  14. Li L, Chen D, Wang C, et al. Autologous platelet-rich gel for treatment of diabetic chronic refractory cutaneous ulcers: A prospective, randomized clinical trial. Wound Repair Regen. 2015; 23(4): 495-505. PMID 25847503
  15. Liu GY, Deng XL, Sun Y, Wang MZ, Gao J, Gou J. Effect of autologous platelet-rich gel on the treatment of diabetic foot ulcers. J Xi'an Jiaotong Univ (Med Sci). 2016;37:264-267.
  16. Liao X, Liang JX, Li SH, et al. Allogeneic Platelet-Rich Plasma Therapy as an Effective and Safe Adjuvant Method for Chronic Wounds. J Surg Res. Feb 2020; 246: 284-291. PMID 31622885
  17. Malekpour Alamdari N, Shafiee A, Mirmohseni A, et al. Evaluation of the efficacy of platelet-rich plasma on healing of clean diabetic foot ulcers: A randomized clinical trial in Tehran, Iran. Diabetes Metab Syndr. 2021; 15(2): 621-626. PMID33740736
  18. Mandadap S. Convectional Dressing versus Platelet Rich Plasma in the Management of Diabetic Foot Ulcers – a Prospective Comparative Study. Int J Pharm Clin Res. (2022) 11:32530.
  19. Meamar R, Ghasemi-Mobarakeh L, Norouzi MR, et al. Improved wound healing of diabetic foot ulcers using human placenta-derived mesenchymal stem cells in gelatin electrospun nanofibrous scaffolds plus a platelet-rich plasma gel: A randomized clinical trial. Int Immunopharmacol. Dec 2021; 101(Pt B):
  20. PMID 34737130
  21. Ma L. Clinical efficacy of autologous platelet rich gel in the treatment of diabetic foot and diabetic chronic cutaneous ulcer. Chin J Mod Drug Appl.2014;8:86-88

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  1. Miłek T, Baranowski K, Zydlewski P, et al. Role of plasma growth factor in the healing of chronic ulcers of the lower legs and foot due to ischaemia in diabetic patients. Postepy Dermatol Alergol. Dec 2017; 34(6): 601-606. PMID 29422826
  2. Orban YA, Soliman MA, Hegab YH, et al. Autologous platelet-rich plasma vs conventional dressing in the management of chronic diabetic foot ulcers. Wounds. Feb 2022; 33(2): 36-42. PMID 35108667
  3. Qi KQ, Chen TJ PJL, Shang XL. The application of autologous platelet-rich gel in the treatment of diabetic foot ulcers. ChinJ Diabetes. 2014;22: 1102-1105.
  4. Rainys D, Cepas A, Dambrauskaite K, et al. Effectiveness of autologous platelet-rich plasma gel in the treatment of hard-to-heal leg ulcers: a randomised control trial. J Wound Care. Oct 02 2019; 28(10): 658-
  5. PMID 31600109
  6. Saad Setta H, Elshahat A, Elsherbiny K, et al. Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. Jun 2011; 8(3): 307-12. PMID 21470370
  7. Satapathy A, Jena SR, Das AK, George JJ, Panda A. Efficacy of autologous platelet rich plasma in treatment of diabetic foot ulcers- a prospective study. J Cardiovasc Dis Res. (2023) 14:120312. doi: 10.31838/jcdr.2023.14.04.146
  8. Saldalamacchia G, Lapice E, Cuomo V, et al. A controlled study of the use of autologous platelet gel for the treatment of diabetic foot ulcers. Nutr Metab Cardiovasc Dis. Dec 2004; 14(6): 395-6. PMID 15853123
  9. Serra R, Grande R, Butrico L, et al. Skin grafting and topical application of platelet gel in the treatment of vascular lower extremity ulcers. Acta Phlebologica. 2014 01 Dec;15(3):129-36.
  10. Singh SP, Kumar V, Pandey A, et al. Role of platelet-rich plasma in healing diabetic foot ulcers: a prospective study. J Wound Care. Sep 02 2018; 27(9): 550-556. PMID 30204574
  11. Steed DL, Goslen JB, Holloway GA, et al. Randomized prospective double-blind trial in healing chronic diabetic foot ulcers. CT-102 activated platelet supernatant, topical versus placebo. Diabetes Care. Nov 1992; 15(11): 1598-604. PMID1468291
  12. Steed DL, Edington HD, Webster MW. Recurrence rate of diabetic neurotrophic foot ulcers healed using topical application of growth factors released from platelets. Wound Repair Regen. 1996; 4(2): 230-3. PMID 17177818
  13. Mohammadi Tofigh A, Tajik M. Comparing the standard surgical dressing with dehydrated amnion and platelet-derived growth factor dressings in the healing rate of diabetic foot ulcer: A randomized clinical trial. Diabetes Res Clin Pract. Mar2022; 185: 109775. PMID 35149167
  14. Xie J, Fang Y, Zhao Y, et al. Autologous Platelet-Rich Gel for the Treatment of Diabetic Sinus Tract Wounds: A Clinical Study. J Surg Res. Mar 2020; 247: 271-279. PMID 31706541
  15. Yang L, Gao L, Lv Y, et al. Autologous platelet-rich gel for lower-extremity ischemic ulcers in patients with type 2 diabetes. International Journal of Clinical and Experimental Medicine. 2017 30 Sep;10(9):13796-801.
  16. Zhao P, Zhou G, Jiang J, et al. Platelet-rich Plasma (PRP) in the Treatment of Diabetic Foot Ulcers and its Regulation of Autophagy. Int J Low Extrem Wounds. Dec 2025; 24(4): 1103-1113. PMID 36652558
  17. Zhang L Qiang D, Sun YH. Clinical observation of autologous platelet rich gel in the treatment of diabetic foot ulcers. Ningxia Med J. 2016;38:809-811.
  18. Zhou XP, Gong YX, Yang ZD, Wang W. Application value analysis of autologous platelet gel in refractory skin ulcer of diabetic patients. World Lat Med Inform. 2015; 15:19-20
  19. Zhu SF, Liu H, Li L, Wang XF. Preliminary application of autologous platelet rich gel in diabetic neuropathic ulcers. Med Innov China. 2012; 9:18-19.
  20. Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) Tracking Sheet for Autologous Blood-Derived Products for Chronic Non-Healing Wounds (CAG-00190R4). 2020; https://www.cms.gov/medicare-coverage-database/details/nca-tracking- sheet.aspx?NCAId=300&NCDId=217. Accessed November 22, 2025.
  21. Qu W, Wang Z, Hunt C, et al. The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds: A Systematic Review and Meta-analysis. Mayo Clin Proc. Sep 2021; 96(9): 2407-2417. PMID 34226023
  22. Oliveira BGRB, Carvalho MR, Ribeiro APL. Cost and effectiveness of Platelet Rich Plasma in the healing of varicose ulcer: Meta-analysis. Rev Bras Enferm. 2020; 73(4): e20180981. PMID 32609173

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  1. Fang Q, Zhang Y, Tang L, et al. Clinical Study of Platelet-Rich Plasma (PRP) for Lower Extremity Venous Ulcers: A Meta-Analysis and Systematic Review. Int J Low Extrem Wounds. Dec 2023; 22(4): 641-653. PMID 34665051
  2. Hu Z, Wang S, Yang H, et al. Efficacy and safety of platelet-rich plasma in the treatment of venous ulcers: A systematic review and meta-analysis of randomized controlled trials. Int Wound J. Feb 2024; 21(2): e14736. PMID 38361238
  3. Saha S, Patra AC, Gowda SP, et al. Effectiveness and safety of autologous platelet-rich plasma therapy with total contact casting versus total contact casting alone in treatment of trophic ulcer in leprosy: An observer-blind, randomized controlled trial. Indian J Dermatol Venereol Leprol. 2020; 86(3): 262-271. PMID 31997794
  4. Shehab AW, Eleshra A, Fouda E, et al. Randomized prospective comparative study of platelet-rich plasma versus conventional compression in treatment of post-phlebitic venous ulcer. Vascular. Dec 2023; 31(6): 1222-1229. PMID35603798
  5. Zhou SF, Estrera AL, Loubser P, et al. Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial. Ann Thorac Surg. Apr 2015; 99(4): 1282-90. PMID 25661906
  6. Serraino GF, Dominijanni A, Jiritano F, et al. Platelet-rich plasma inside the sternotomy wound reduces the incidence of sternal wound infections. Int Wound J. Jun 2015; 12(3): 260-4. PMID 23692143
  7. Zhu S, Gao J, Yu W, et al. Platelet-rich plasma influence on the sternal wounds healing: A meta-analysis. Int Wound J. Nov 2023; 20(9): 3794-3801. PMID 37350616
  8. Sidman JD, Lander TA, Finkelstein M. Platelet-rich plasma for pediatric tonsillectomy patients. Laryngoscope. Oct 2008;118(10): 1765-7. PMID 18622315
  9. El-Anwar MW, Nofal AA, Khalifa M, et al. Use of autologous platelet-rich plasma in complete cleft palate repair. Laryngoscope. Jul 2016; 126(7): 1524-8. PMID 27075516
  10. Dinaki K, Grigoriadis N, Vizirianakis IS, et al. The impact of submucosal PRP injection on wound healing after endoscopic sinus surgery: a randomized clinical trial. Eur Arch Otorhinolaryngol. Jul 2024; 281(7): 3587-3599. PMID 38334783
  11. Almdahl SM, Veel T, Halvorsen P, et al. Randomized prospective trial of saphenous vein harvest site infection after wound closure with and without topical application of autologous platelet-rich plasma. Eur J Cardiothorac Surg. Jan 2011; 39(1):44-8. PMID 20634084
  12. Mohamadi S, Norooznezhad AH, Mostafaei S, et al. A randomized controlled trial of effectiveness of platelet-rich plasma gel and regular dressing on wound healing time in pilonidal sinus surgery: Role of different affecting factors. Biomed J. Dec 2019; 42(6): 403-410. PMID 31948604
  13. Slaninka I, Fibír A, Kaška M, et al. Use of autologous platelet-rich plasma in healing skin graft donor sites. J Wound Care. Jan 02 2020; 29(1): 36-41. PMID 31930949
  14. Kazakos K, Lyras DN, Verettas D, et al. The use of autologous PRP gel as an aid in the management of acute trauma wounds. Injury. Aug 2009; 40(8): 801-5. PMID 18703188
  15. Marck RE, Gardien KL, Stekelenburg CM, et al. The application of platelet-rich plasma in the treatment of deep dermal burns: A randomized, double-blind, intra-patient controlled study. Wound Repair Regen. Jul 2016; 24(4): 712-20. PMID27169627
  16. Yeung CY, Hsieh PS, Wei LG, et al. Efficacy of Lyophilised Platelet-Rich Plasma Powder on Healing Rate in Patients With Deep Second Degree Burn Injury: A Prospective Double-Blind Randomized Clinical Trial. Ann Plast Surg. Feb 2018;80(2S Suppl 1): S66-S69. PMID 29369904
  17. Huang H, Sun X, Zhao Y. Platelet-rich plasma for the treatment of burn wounds: A meta-analysis of randomized controlled trials. Transfus Apher Sci. Feb 2021; 60(1): 102964. PMID 33127309
  18. Imam MS, Alotaibi AAS, Alotaibi NOM, et al. Efficiency of platelet-rich plasma in the management of burn wounds: A meta-analysis. Int Wound J. Sep 30 2023; 21(2). PMID 37776166
  19. Qaseem A, Humphrey LL, Forciea MA, et al. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Mar 03 2015; 162(5): 370-9. PMID 25732279
  20. Association for the Advancement of Wound Care (AAWC). Guideline of Pressure Ulcer Guidelines. Malvern, PA: AAWC;2010.
  21. Association for the Advancement of Wound Care (AAWC). International Consolidated Venous Ulcer Guideline (ICVUG).2015;

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https://aawconline.memberclicks.net/assets/appendix%20c%20guideline%20icvug- textformatrecommendations-final%20v42%20changessaved18aug17.pdf. Accessed November 25, 2025.

  1. Gould LJ, Alderden J, Aslam R, et al. WHS guidelines for the treatment of pressure ulcers-2023 update. Wound Repair Regen. 2024; 32(1): 6-33. PMID 37970711
  2. Lavery LA, Suludere MA, Attinger CE, et al. WHS (Wound Healing Society) guidelines update: Diabetic foot ulcer treatment guidelines. Wound Repair Regen. 2024; 32(1): 34-46. PMID 38032324
  3. National Institute for Health and Clinical Excellence (NICE). Diabetic foot problems: prevention and management [NG19]. 2019; https://www.nice.org.uk/guidance/ng19/resources/diabetic-foot- problems-prevention-and-management-pdf-1837279828933. Accessed November 25, 2025.
  4. Centers for Medicare & Medicaid Services (CMS). Decision Memo for Autologous Blood-Derived Products for Chronic Non-Healing Wounds (CAG-00190R3). 2012; https://www.cms.gov/medicare- coverage-database/details/nca-decision-memo.aspx?NCAId=260. Accessed November 23, 2025.
  5. Centers for Medicare & Medicaid Services (CMS). CMS Manual System: Pub 100-3 Medicare National Coverage Determinations (Transmittal 127). 2010 Oct; https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R127NCD.pdf. Accessed November 25, 2025.
  6. Centers for Medicare & Medicaid Services (CMS). Decision Memo for Autologous Blood Derived Products for Chronic Non-Healing Wounds (CAG-00190R2). 2008; https://www.cms.gov/medicare- coverage-database/details/nca-decision-memo.aspx?NCAId=208. Accessed November 24, 2025.
  7. Qu W, Wang Z, Hunt C, Morrow AS, Urtecho M, Amin M, Shah S, Hasan B, Abd-Rabu R, Ashmore Z, Kubrova E, ProkopLJ, Murad MH. Platelet-Rich Plasma for Wound Care in the Medicare Population. Technology Assessment Program Project ID 040-353-492. (Prepared by the Mayo Clinic Evidence- based Practice Center under Contract No.HHSA290201500013I.) Rockville, MD: Agency for Healthcare Research and Quality. https://pubmed.ncbi.nlm.nih.gov/34978778/. Accessed November 25, 2025.

  8. Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) for Autologous Blood-Derived Products for Chronic Non-Healing Wounds (CAG-00190R4). 2021; https://www.cms.gov/medicare-coverage-database/view/ncacal-decision- memo.aspx?proposed=N&ncaid=300. Accessed November 20, 2025.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS

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