Does G0465 require prior authorization?

No, G0465 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for G0465?

Medicare facility rate: $83.84. Non-facility rate: $1063.48. Work RVU: 1.78.

Verity

`G0465` — Autologous platelet rich plasma (prp) or other blood-derived product for diabetic chronic wounds/ulcers, using an fda-cleared device for this indication, (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Medicare Pricing

Work RVU

1.78

Facility

$83.84

Non-Facility

$1063.48

Documentation Required

This billing and coding guidance complements Local Coverage Determination (LCD) L38745 for Platelet Rich Plasma; refer to LCD L38745 for specific clinical indications, coverage rules, and required documentation.
Follow the Local Coverage Determination L39058 and CMS NCD 270.3 for clinical indications and supporting documentation to justify PRP use and appropriate code selection.

For diabetic foot ulcers: PRP discussed 'as an adjunct to conventional wound therapy (CWT) to treat adults who have hard-to-heal diabetic foot ulcers (DFUs) that have not responded to prolonged standalone CWT' (Hayes Technology Assessment) — documentation of prior prolonged CWT and 'hard-to-heal' status is implied/required by the evidence base.

No specific documentation requirements are listed in this policy. No explicit UnitedHealthcare documentation checklist is provided in the text. Inferred/explicit trial inclusion-type requirements referenced in the literature (these appear as conditions in cited studies and assessments and could be used as documentation expectations):

For lateral epicondylitis: PRP identified as 'a minimally invasive treatment option for patients with persistent LE that is unresponsive to other conservative measures.' (Hayes 2021/2022 update) — documentation of prior conservative treatment failure is implied.

Key Coverage Criteria

Platelet-rich plasma (PRP) used for treatment of chronic non-healing wounds is covered when it meets CMS National Coverage Determination (NCD) 270.3; bill using HCPCS G0460/G0465 accordingly.
HCPCS P9020 should be billed for one or more units of PRP transfused when used to treat conditions or coagulopathies for which PRP transfusion is indicated.
None — "Due to insufficient evidence of efficacy, the following are unproven and not medically necessary for any condition or indication: - Prolotherapy - Platelet-rich plasma" Adhesive capsulitis (frozen shoulder) — PRP studied as a treatment option (Blanchard et al. 2023 systematic review). [...]
Implied/mentioned clinical contexts: treatment of chronic wounds (wounds that have failed to progress through normal healing stages).
PRP source types described (relevant to use): autologous PRP (patient-derived) and homologous PRP (donor-derived).
treatment of chronic, nonhealing cutaneous wounds that persist for 30 days or longer and fail to properly complete the healing process.

9 Active Policies

HUMANA-PLATELET-RICH-PLASMA-FOR-WOUND-HEALING-MA — Platelet Rich Plasma for Wound Healing - Medicare Advantage

L39058 — Platelet Rich Plasma Injections for Non-Wound Injections

ANTHEM-MP-B094276 — TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products

A58282 — Billing and Coding: Platelet Rich Plasma

A58788 — Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections

L38745 — Platelet Rich Plasma

UHC-POL-prolotherapy-platelet-rich-plasma-therapies — Prolotherapy and Platelet Rich Plasma Therapies

UMR-POL-UMR-prolotherapy-platelet-rich-plasma-therapies — Prolotherapy and Platelet Rich Plasma Therapies

SUREST-POL-SUREST-prolotherapy-platelet-rich-plasma-therapies — Prolotherapy and Platelet Rich Plasma Therapies

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?