Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

This policy covers use of recombinant and autologous platelet‑derived growth factors (e.g., topical becaplermin and platelet‑rich plasma) for wound healing and other non‑orthopedic indications, including adjunctive use for full‑thickness (stage III/IV) neuropathic diabetic foot ulcers extending into subcutaneous tissue, offloadable pressure ulcers, and selected surgical adjunct applications. Coverage requires inclusion in the member’s benefit plan and supportive evidence from authoritative compendia or two peer‑reviewed articles, and is limited to specified criteria (e.g., TcPO2 ≥30 mm Hg, participation in a wound‑management program, adequate albumin/lymphocyte/vitamin levels, ability to offload); many uses (such as ischemic or venous stasis ulcers and most PRP wound applications) are considered experimental/investigational.

"Drug therapy when proven effective for the relevant diagnosis and consistent with recommendations from at least one authoritative source"