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LCD L38937: Platelet Rich Plasma

LCD L38937, Platelet Rich Plasma, is the Local Coverage Determination that Wellpoint Federal applies to claims from 13 states (CT, DN, IL, MA, ME, MN, NH, NY and others), effective 2026-04-01 and first in force 2021-08-01. The policy text runs 23 words. 3 other contractors publish a policy with the same title, so the criteria that apply depend on where the service is furnished.

QuickIntell editorial content · Legacy registry date · Review not verified

Data effective
Data currency: Medicare Coverage Database LCD export release of September 24, 2026 (effective September 20, 2026). Next CMS release: weekly (Thursdays) for the MCD.
Contractor
Wellpoint Federal
States and territories
13
CT DN IL MA ME MN NH NY QN RI UN VT WI
Revision effective
2026-04-01
Original effective
2021-08-01
Policy text
23 words
Covered ICD-10 codes (articles)
0

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L38937
ContractContractorTypeStates
06101Wellpoint FederalMAC - Part AIL
06201Wellpoint FederalMAC - Part AMN
06301Wellpoint FederalMAC - Part AWI
06102Wellpoint FederalMAC - Part BIL
06202Wellpoint FederalMAC - Part BMN
06302Wellpoint FederalMAC - Part BWI
13101Wellpoint FederalA and B and HHH MACCT
13201Wellpoint FederalA and B and HHH MACNY
13102Wellpoint FederalA and B and HHH MACCT
13202Wellpoint FederalA and B and HHH MACDN
13282Wellpoint FederalA and B and HHH MACUN
13292Wellpoint FederalA and B and HHH MACQN
14411Wellpoint FederalA and B and HHH MACRI
14211Wellpoint FederalA and B and HHH MACMA
14311Wellpoint FederalA and B and HHH MACNH
14511Wellpoint FederalA and B and HHH MACVT
14111Wellpoint FederalA and B and HHH MACME
14112Wellpoint FederalA and B and HHH MACME
14212Wellpoint FederalA and B and HHH MACMA
14312Wellpoint FederalA and B and HHH MACNH
14512Wellpoint FederalA and B and HHH MACVT
14412Wellpoint FederalA and B and HHH MACRI

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A58609 (Billing and Coding: Platelet Rich Plasma) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A58609: Billing and Coding: Platelet Rich Plasma (Billing and Coding, effective 2026-04-01)

Covered ICD-10-CM codes
0
0 groups
Non-covered ICD-10-CM codes
0
Procedure codes listed
4
Full article
cms.gov record

Procedure codes: 0232T, 0481T, M0076 (Prolotherapy), P9020 (Platelet Rich Plasma, Each Unit).

Coverage indications, limitations and medical necessity

This is a NON-coverage policy for all platelet rich plasma injections and/or applications as a means of managing musculoskeletal injuries and/or joint conditions.

Summary of evidence (opening)

Introduction

Platelet-rich plasma (PRP) is defined as a platelet-rich concentrate with platelet levels greater than the baseline platelet count in whole blood. This autologous derived substance, also referred to as autologous platelet-derived growth factors, platelet gel, platelet-rich concentrate, autogenous platelet gel, plasma rich in growth factors or platelet releasate, has been proposed for the treatment of multiple conditions to enhance healing. Theoretically, these growth factors function as a mitogen for fibroblasts, smooth muscle cells, osteoblasts and vascular endothelial growth factors. 1,2 While PRP may work by activating the innate immune response and stimulating tissue anabolism, its precise mechanism of action is still unclear. 2 The role that white blood cells may play is particularly unclear, as the immune cells may act as antimicrobial and/or proinflammatory agents. Furthermore, PRP preparations are not standardized and exhibit wide variability in platelet and white blood cell concentrations and the use of thrombin activators. The way in which variations in PRP composition may impact clinical outcomes is also unclear. 3 Mishra et al. 4 proposed classifying these types in three categories: the presence of white blood cells (e.g., leukocyte-rich or -poor), whether the PRP is activated or not, and the concentration of platelets.

A number of factors have contributed to the growing popularity of biologic therapies despite the dearth of high-quality clinical trials supporting their use. Musculoskeletal conditions are both serious and prevalent. Conventional treatment, for the most part, is lacking in success. Platelet-rich plasma has the appeal of a simple, minimally invasive treatment with little regulation, which can be easily administered via local injection by clinicians. In addition, the biotechnology companies that manufacture the equipment used to assist in the production of these therapies have conducted nation-wide marketing directly to clinicians and consumers, touting success with high profile professional athletes.

A collection and preparation system is used to collect a small sample of blood at the patient’s point of care or clinical laboratory. The systems used for preparing autologous platelet-derived growth factors are Federal Drug Administration (FDA) approved under the 510(k) process. While the technology to obtain PRP is FDA-approved, PRP itself is currently not indicated for direct injection. Centrifugation of this blood sample separates the denser red cells from the plasma. The plasma components are divided into a buffy coat and an adjacent layer. The buffy coat contains leucocytes and most of the platelets. The adjacent layer of plasma is less rich in platelets and has few leucocytes. 5

The contractor cites 58 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective
2021-08-01
Current revision effective
2026-04-01
MCD version
7

The contractor lists one National Coverage Determination as related: NCD 270.3 Blood-Derived Products for Chronic Non-Healing Wounds. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

Other related documents: A58819 (Response to Comments).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wellpoint Federal hub lists every other active policy from the same contractor.

The same policy title at other contractors

Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.

L38745
Palmetto GBA · 7 states · revised 2025-03-13
L39068
Novitas Solutions, Inc. · 12 states · revised 2021-12-12
L39071
First Coast Service Options, Inc. · 3 states · revised 2021-12-12

Frequently asked questions

What does LCD L38937 cover?

This is a NON-coverage policy for all platelet rich plasma injections and/or applications as a means of managing musculoskeletal injuries and/or joint conditions. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L38937 apply to?

Wellpoint Federal applies it to Medicare claims in CT, DN, IL, MA, ME, MN, NH, NY, QN, RI, UN, VT, WI. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L38937?

The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.

How do I appeal a denial under LCD L38937?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.