Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for platelet-rich plasma injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the nature of Statutory Criteria/Case Summary: There is limited reliable clinical evidence to guide the use of platelet-rich plasma injections. Although no major long-term or permanent complications have been reported in relatively short-term clinical trials, it remains to be seen what the results will be with more widespread application of platelet-rich plasma injections in the knee. Long-term benefits of platelet-rich plasma injections have not been demonstrated yet in the knee. Short-term benefits, lasting from six months to over a year, include functional improvement and pain relief. Such effects have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. The effects of platelet-rich plasma on knee osteoarthritis are quite mixed, and the research is not high quality. The majority of published data suggests better symptomatic relief with early osteoarthritis.  In this patients case, there are no reports of standing knee radiographs grading the degree of osteoarthritis or magnetic resonance imaging (MRI) reports showing how much articular degeneration is present.  This patient is 59 years old, and the cited studies demonstrate decreased efficacy in individuals age 50 or older.  In addition, the overall body of supporting literature is of poor quality and fails to demonstrate improved outcomes with platelet-rich plasma injections compared to standard available therapies for the treatment of knee osteoarthritis.  Therefore, platelet-rich plasma injections were not likely to have been superior over other available treatment options. Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.