Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elbow Pain.
Treatment: Injection Of Platelet Rich Plasma (PRP).

The insurer denied the Injection Of Platelet Rich Plasma (PRP). The denial is upheld.

The patient is a right-hand-dominant female. She was being evaluated for right elbow pain.  Has diagnosis of "right tennis elbow" has had treatments with conservative modalities, orthosis, activity modification, anti-inflammatories, cortisone injection.  She had a cortisone injection, which provided only one week of relief.

No, the health plan should not cover the treatment with Platelet-Rich Plasma.

Platelet-rich plasma injection for treatment of lateral epicondylitis is not proven to be more efficacious or long-lasting compared to other nonoperative modalities, such as cortisone injection.

No, treatment with Platelet-Rich Plasma is not proven to have better outcome than other modalities. 

Per the reference below (1):
"Abstract
Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow.

Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group.

Study design: Randomized controlled trial; Level of evidence, 2.

Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n [number] = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain.

Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P [mean] = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P [mean] = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group.

Conclusion: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group."

Progress note, which is a visit via telemedicine, indicates that the patient has right elbow pain due to lateral epicondylitis. She has failed conservative treatment. Her options are not limited and she may want to consider "PRP injection or arthroscopic debridement." It is noted that although there is no urgency to proceed with surgery, it is unlikely that other modalities will provide much relief.

Report of radiographs elbow AP (anteroposterior) and lateral indicates no osseous or articular abnormality, alignment is preserved, no elbow joint effusion, no significant soft tissue abnormality.