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

A 49-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Apheresis Plasma Therapeutic treatments over a 4-month period .for treatment of the enrollees right knee meniscus tear.  Findings:  Three physician reviewers found that a magnetic resonance imaging (MRI) imaging scan was interpreted to show a recurrent torn medial meniscus 1 cm complex. The patient has been treated with viscosupplementation with Synvisc, opioids and steroid local injections. On physical examination a month prior to the dates in question, the patient reported that the right knee Synvisc injection from seven months prior did not offer her much symptomatic relief. On that date, the patients current medications included Flexeril, Celebrex, Percocet, Metoprolol, Pristiq, and Zoloft. The provider reports the patient has failed treatment with Motrin, Naprosyn, Mobic, Relafen, and Voltaren. On physical knee examination the provider noted no deformity or swelling, with quadricep atrophy present. There was no limitation in flexion extension, with presence of tenderness over the medial joint line. The patients right knee was stable to valgus and varus stress. She had a negative drawer sign, Lachman test, and pivot shift, as well as negative posterior drawer test and reverse pivot test. The provider noted the McMurrays test was positive and there was popliteal fossa swelling. The patient was diagnosed with osteoarthrosis of the ankle and foot, tarsal tunnel syndrome, bunion, old disruption of lateral collateral ligament, knee pain, lumbar spondylosis, myalgia, and myositis. The patient was treated with apheresis plasma injections to the right knee on various dates and has requested coverage for this treatment. On review of the available medical literature, it is not likely that platelet rich plasma will lead to healing of a documented meniscal tear in this patient, or an improved health outcome beyond that anticipated with standard therapies. Platelet rich plasma is an autologous blood derived product with an increased concentration of platelets rich in growth factors. Although the growth factors are increased, it has not been shown to enhance healing of tissue by recruitment, proliferation, and differentiation of cells involved in tissue regeneration. Injection of platelet rich plasma into the joint cannot be expected to bring about a healing of the meniscal tear. Platelet rich plasma has a number of growth factors in the plasma and buffy coat of the centrifuged blood. These epidermal growth factors, fibroblast growth factors, transforming growth factors, insulin growth factors have all been isolated from the buffy coat and plasma of centrifuged blood. The widest application for platelet rich plasma is in wound care. Overall, the efficacy of healing a meniscal tear through injection of platelet rich plasma has not been demonstrated. In the article from Vavken and colleagues, a review of the current evidence for the effects of platelet concentration on graft maturation and bone graft interface healing in anterior cruciate ligament (ACL) reconstruction was performed. The current evidence was noted to show a very limited influence of platelet concentrates on bone graft interface healing and no significant difference in clinical outcomes. In the prospective study by Nin and colleagues, 100 patients underwent arthroscopic patella tendon allograft ACL reconstruction with 50 patients receiving a platelet enriched gel. At two-year follow-up, there was inadequate evidence that platelet rich plasma had any clinical or biomechanical effects. In the absence of scientific data demonstrating that the use of platelet rich plasma is superior over standard care, it was not and is not likely to be of substantial benefit in healing of this patients meniscal tear.