Platelet-rich Plasma Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for a platelet-rich plasma (PRP) injection to the left foot. PRP is a rich source of growth factors and cytokines that stimulate the natural healing process of many tissue types. They modulate neovascularization and angiogenesis, promote mitogenesis, improve production of type 1 collagen, and have anti-inflammatory effects. Corticosteroid injections (CSI) inhibit fibroblast proliferation and expression of ground substance protein. Current medical literature documents multiple side effects with CSI, including plantar fascial tear, fat pad atrophy, abscess, and osteomyelitis. Breton and colleagues note that therapy with CSI has a high recurrence rate and a risk of rupture in ten percent of patients.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma (PRP) injections for the right knee. This patient sustained a right knee injury and was diagnosed with a grade 3 medial collateral ligament (MCL) tear, anterior cruciate ligament (ACL) tear, medial meniscus tear, and lateral meniscus tear. She underwent ACL reconstruction with medial and lateral meniscus repair. Surgical augmentation with PRP was given as the MCL and meniscal capsular junction were not repaired surgically. A subsequent PRP injection was performed to the posterior lateral corner ligaments including popliteus, arcuate ligament, popliteal fibular ligament, and fibular collateral ligament.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for (1) bilateral platelet-rich plasma injections (to both knees, (2) platelet-rich plasma injections to left knee, and (3) bilateral platelet-rich plasma injections every six months to both knees. Researchers report, “Among patients with symptomatic mild to moderate radiographic knee osteoarthritis, intra-articular injection of platelet-rich plasma, compared with injection of saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months. These findings do not support use of platelet-rich plasma for the management of knee osteoarthritis.” Researchers explain that platelet-rich plasma works by delivering a supraphysiologic amount of growth factors and cytokines contained within platelets.

Findings: The physician reviewer found that an enrollee has requested platelet-rich plasma (PRP) injections to the left knee. There are limited large-scale, long-term references showing the safety and efficacy of PRP injections. Researchers report, “Among patients with symptomatic mild to moderate radiographic knee osteoarthritis, intra-articular injection of PRP, compared with injection of a saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months.” The efficacy of PRP injections has not been proven in long-term, peer-reviewed studies. Researchers explain, “PRP works by delivering a supraphysiologic amount of growth factors and cytokines contained within platelets. In musculoskeletal medicine, PRP is a promising treatment modality with clear evidence of safety.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Platelet-rich Plasma Injection, then check the rights and deadlines that apply to your plan.