Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for preparation and injection of platelet rich plasma (PRP) for treatment of the enrollee, who has bilateral foot pain.Findings:  Three physician reviewers found that the patient has a history of multiple surgeries performed on both feet.  The patient has had bilateral bunion corrections, neuroma excision in the left foot, and forefoot reconstruction of the right foot. At the present time, the patient has chronic pain, at the area of the second and third interspaces of the left foot from a stump neuroma, and chronic pain of the right foot. The patients provider recommends continued use of Voltaren gel and Lidocaine patch, continued physical therapy, wearing of stiff soled shoe, and work restrictions. The provider discussed several treatment options with the patient including the possibility of amputation of third toe to alleviate chronic third toe pain, right foot. The provider discontinued injections of sclerosing agents, as these were too painful for the patient. The patient reported to her current provider that she has had one previous treatment with platelet rich plasma (PRP) injections with improvement of symptoms. The patient underwent injections under local anesthesia of PRP into right and left forefoot. The patient reported a 60% improvement, but still has pain. An examination on 7/12/16 showed less pain in both feet. The patient requested a second series of PRP injections. The Health Plan denied the requested preparation and injection of PRP as investigational for the treatment of this patients medical condition. There is a lack of support in the medical literature to indicate the effectiveness of the requested services in this patients case. In a study a randomized controlled trial was performed on patients with chronic Achilles tendinopathy.  Patients were equally divided to receive either PRP or saline injections. The study showed no significant differences in pain or activity levels between the two groups.  A case controlled study of twelve athletes who underwent surgical repair of a complete Achilles tendon tear to see if PRP promotes healing and functional recovery. The authors concluded that while PRP may enhance healing and functional recovery, further studies were needed to verify outcomes. The use of PRP for tendon and ligament injuries showed no statistically significant benefit.  For muscle injury, clinical evidence was also insufficient. For treatment of plantar fasciitis, the evidence is conflicting, and demonstrates an incomplete assessment of net benefit versus harm.  According to the medical literature, additional studies and research are warranted. Therefore, while PRP injections appear to be a promising treatment modality, the medical literature suggests more robust research, using large, methodologically-sound randomized controlled trials, are required in order to determine PRPs efficacy in treatment of musculoskeletal conditions. Most studies involved are anecdotal or case reports. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in podiatry and are actively practicing. The reviewers are experts 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.