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 female with chronic right elbow pain. She had received treatments of orthosis, corticosteroid injection and medication without benefit. Her physician recommended PRP (platelet-rich plasma) injection as an alternative to surgery. 
No, the health plan should not cover the treatment with Platelet-Rich Plasma.
No, the treatment with Platelet-Rich Plasma is not likely to be more beneficial.
The scientific literature has not demonstrated consistent efficacy for use of PRP and chronic lateral epicondylitis.  A search was completed utilizing the National Library of Medicine. The key words were platelet rich plasma and lateral epicondylitis. The references demonstrated benefit, however there were a limited number of patients evaluated for short term follow-up. 
The references reported no difference in short term outcomes compared to several other modes of treatment. They did report benefit at long term (albeit 24 weeks). The references recommended additional studies be completed prior to acceptance. The references were inconclusive and reported insufficient evidence to substantiate use as standard of care. 
The health plan's decision was in accordance with current national standards and criteria.
According to the Official Disability Guidelines - "Elbow: Not recommended as a primary first-line treatment for epicondylitis. PRP is not recommended for other elbow conditions (eg, arthritis, bursitis, ligament injury) which lack sufficient evidence. PRP may be considered only as second-line treatment for severe chronic (>1 year) recalcitrant lateral epicondylitis, using a single injection of LR-PRP (platelet-rich plasma) (without fluoroscopic or ultrasound guidance), following failure of first-line physical therapy (eccentric stretching and strengthening), bracing, and time. Almost all "tennis elbow" conditions resolve spontaneously by 1 year, even without treatment. PRP benefit may then be anticipated in over 80%, with a very low risk of complications compared to more disfavored corticosteroid injection (CSI) or autologous blood injection (ABI). The alternative of surgery for lateral epicondylitis has higher inherent risks, without reported success rates much higher than 80%.
An RCT (randomized controlled trial) (n [number] = 60) found that neither CSI nor PRP were any better than saline injections for lateral epicondylitis. At 1-month pain reportedly dropped by almost 10 on a 50-point scale with CSI, compared to less than 2 points for the PRP and saline groups. However, by 3 months any benefit due to CSI disappeared, with pain and function being similar across all 3 groups. The authors noted that other studies had suggested subsequent (> 3 months) improvement with PRP, while CSI only provided short-term relief with potential for further tendon damage. With epicondylitis symptoms lasting weeks and months, watchful waiting would be the most appropriate treatment, especially since 80% of patients will be cured by 1 year. (Krogh) A prospective double-blinded multicenter RCT with active controls, where 230 extensor tendon origins were needled with or without LR-PRP (platelet-rich plasma), demonstrated no significant outcome differences at 12 weeks; although by 24 weeks some clinically meaningful improvements were noted in the PRP group compared with controls. 24-week success rates of 84% were reported for the PRP group compared to 68% for controls, with no significant complications. (Mishra)
An SR (systemic review) of 6 RCTs (randomized controlled trials), 4 considered to be of high-quality, comparing PRP efficacy to control agents (bupivacaine, ABI (autologous blood injection), CSI) for treatment of lateral epicondylar tendinopathy concluded that PRP did not significantly improve outcomes. (deVos) An SR/MA (systemic review/meta-analysis) suggested better than placebo outcomes for PRP and ABI (autologous blood injection) for lateral epicondylitis, although the "peppering techniques" (needling) seemed to add no additional benefit. (Dong) Another SR/MA (systemic review/meta-analysis) of 10 studies involving results of epicondylar CSI, PRP, and ABI noted little sustained improvement with corticosteroid, but a mild benefit of PRP with low risk of complications, and mild effectiveness of ABI with a higher risk of adverse effects. (Arirachakaran) An MA (meta-analysis) of 8 RCTs (randomized controlled trials) (511 patients) comparing PRP and CSI for lateral epicondylitis suggested that PRP  may be associated with improved pain relief and function at 12 months; however, the authors noted study limitations including variation in PRP concentrations and dosage, as well as pain and function scoring methodologies. (Mi) An MA (meta-analysis) of 18 studies and 1066 patients, including 8 considered to have low risk of bias, concluded that a single injection of highly cellular LR-PRP (platelet-rich plasma) provided a strongly positive effect when compared to LP-PRP (platelet-rich plasma), while no outcome differences were noted between control groups (saline, local anesthetic, CSI, or dry needling). (Fitzpatrick) An SR/MA (systemic review/meta-analysis) of 12 RCTs (randomized controlled trials) comparing efficacy of PRP to CSI, bupivacaine, and ABI for lateral epicondylitis (follow-up 3 weeks to 24 months) found conflicting results demonstrating superiority of PRP over other agents. (Franchini)"