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.

HCPCS/CPT

No Prior Auth Required

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

Work RVU

1.78

Facility

$83.84

Non-Facility

$1063.48

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.
When billing P9020, document the number of PRP units transfused (bill one or more P9020 units equal to units transfused); when billing 0232T, document that a kit was used to prepare PRP and that the service is an injection.
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.

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). [...]
Due to insufficient evidence of efficacy, the following are unproven and not medically necessary for any condition or indication: Prolotherapy, Platelet-rich plasma
Due to insufficient evidence of efficacy, the following are unproven and not medically necessary for any condition or indication: Prolotherapy; Platelet-rich plasma
CMS National Coverage Determinations (NCDs) exist for autologous PRP for the treatment of chronic non-healing diabetic wounds. For coverage guidelines, refer to the NCD for Blood-Derived Products for Chronic Non-Healing Wounds (270.3).

NORIDIAN-L39058, Platelet Rich Plasma Injections for Non-Wound Injections

PALMETTO-JJ-L38745, Platelet Rich Plasma

PALMETTO-JM-L38745, Platelet Rich Plasma

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

Ask Verity about documentation requirements, denial risks, or coverage in your state.