CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Prolotherapy

Defines coverage position for prolotherapy (proliferant injections/joint sclerotherapy) for musculoskeletal pain for Medicare Advantage and commercial products from Blue Cross Blue Shield - Rhode Island. States whether procedure is covered and provides background, coding, and references.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Prolotherapy

Policy CodePolicy N/A

Change TypeClarified - not covered / not medically necessary

Effective DateAug 2, 2007

Next Review Date

Key ActionVerify member-specific benefits, eligibility, and whether the subscriber agreement/benefit booklet allows coverage, since benefits may vary between groups and contracts and those documents supersede the medical policy.

SourceLink

POLICY UPDATE CHANGES

Policy states prolotherapy is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products due to insufficient evidence.

1HCPCS code listed as not covered

2Payer product types with same stance (Medicare Advantage, Commercial)

1999-2021Key references date range (CMS NCD 1999 to reviews up to 2021)

Coverage Summary

This policy covers the use of Prolotherapy (also called proliferant injection, prolo, joint sclerotherapy, regenerative injection therapy) for musculoskeletal pain. The document status is CURRENT for the subject Prolotherapy, with an effective date of 08/02/2007 and last review on 01/24/2022. The coverage stance is that prolotherapy is not covered / not medically necessary for treatment of musculoskeletal pain because the evidence is insufficient to demonstrate an improvement in net health outcome. Evidence summary: small randomized trials with inconsistent results, with the strongest but uncertain evidence for osteoarthritis.

Key policy facts

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy - Prolotherapy

SubjectProlotherapy (proliferant injections/joint sclerotherapy)

Coverage stanceNot covered / Not medically necessary (prolotherapy not covered for Medicare Advantage; not medically necessary for Commercial Products)

Effective date2007-08-02

Last review2022-01-24

StatusCURRENT

Medical Necessity / Coverage Determinations

Medicare Advantage Plans - Coverage Determination

Prolotherapy coverage determination:

Prolotherapy is not covered as a treatment of musculoskeletal pain because the evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Commercial Products - Coverage Determination

Prolotherapy coverage determination for commercial products:

Prolotherapy is not medically necessary as a treatment of musculoskeletal pain because the evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Overall evidence conclusion: Insufficient to determine improvement in net health outcome for musculoskeletal pain. The evidence base consists of small randomized trials with inconsistent results; the strongest body of evidence evaluates prolotherapy for osteoarthritis, but the clinical significance of observed therapeutic results is uncertain.

Not Covered / Not Medically Necessary

Policy position: For Medicare Advantage Plans, prolotherapy is not covered for musculoskeletal pain because the evidence is insufficient to show improved net health outcomes. For Commercial Products, prolotherapy is considered not medically necessary for musculoskeletal pain for the same reason. The policy lists HCPCS code M0076 (Prolotherapy) as not covered / not medically necessary. As a related determination, CMS National Coverage Determination NCD 150.7 (1999) addresses prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agents.

Provider Actions

Documentation Required

Benefit verification

Verify member-specific benefits, eligibility, and whether the subscriber agreement/benefit booklet allows coverage, since benefits may vary between groups and contracts and those documents supersede the medical policy.

Benefits may vary between groups and contracts.

Denial Risk

Claims for prolotherapy

Claims submitted for prolotherapy (M0076) for musculoskeletal pain are subject to denial as not covered / not medically necessary per this policy.

M0076

Background and Definitions

Background: Prolotherapy is intended to heal and strengthen ligaments and tendons by injecting an agent that induces inflammation and stimulates endogenous repair mechanisms (also called proliferant injection, prolo, joint sclerotherapy). Agents used have included dextrose, glycerin, phenol combinations, zinc sulfate, psyllium seed oil, polidocanol, sodium morrhuate, and autologous platelet-rich plasma (PRP). Treatments typically involve multiple injections per session delivered over a series of treatment sessions. The evidence consists of small randomized trials with inconsistent results across indications; outcomes assessed include symptoms, function, and quality of life, with the strongest but uncertain evidence in osteoarthritis.

Definitions: Prolotherapy — Procedure intended for healing and strengthening ligaments and tendons by injecting an agent that induces inflammation and stimulates endogenous repair mechanisms; also called proliferant injection, prolo, joint sclerotherapy, regenerative injection therapy.

Name	Number	Effective Year	Type
Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents	150.7	1999	NCD

Revision History

01|24|2022coding clarificationLatest

Clarified that HCPCS code M0076 (Prolotherapy) is listed as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products; policy scope states prolotherapy is not covered/not medically necessary due to insufficient evidence to demonstrate improvement in net health outcome for musculoskeletal pain.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Prolotherapy

Policy CodePolicy N/A

Change TypeClarified - not covered / not medically necessary

Effective DateAug 2, 2007

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy | Prolotherapy

Coverage Summary

Medical Necessity / Coverage Determinations

Not Covered / Not Medically Necessary

Coding

Provider Actions

Background and Definitions

Medicare Determinations

Revision History