Prolotherapy and Platelet Rich Plasma Therapies (for Idaho Only)
State-specific UnitedHealthcare medical policy (Idaho, including Idaho Medicaid Plus) addressing coverage determination for platelet-rich plasma and prolotherapy injections, with supporting description and evidence review; includes applicable procedure and supply codes for reference.
Policy Summary
PayerUnitedHealthcare
PolicyProlotherapy and Platelet Rich Plasma Therapies (for Idaho Only)
Policy CodePolicy CS1O3ID.A
Change TypeNo material change (evidence summary / reaffirmation)
Effective DateJune 1, 2025
Next Review Date
Key ActionClaims for platelet-rich plasma (PRP) and prolotherapy are considered unproven and not medically necessary for any condition or indication per this policy and are subject to denial.
POLICY UPDATE CHANGES
No material clinical or coverage changes were made; this policy summarizes evidence and maintains prior coverage stance.
2Therapies classified as not medically necessary
5Applicable reference codes listed
low-to-very-lowEvidence quality
heterogeneousStudy heterogeneity / limitations
multipleIndications reviewed
Coverage Summary
State-specific UnitedHealthcare medical policy (Idaho only) covering prolotherapy and platelet-rich plasma (PRP) injections. This policy applies only to services provided in the state of Idaho (including Idaho Medicaid Plus) and is effective June 1, 2025. The policy concludes that, due to insufficient evidence of efficacy, platelet-rich plasma and prolotherapy are unproven and not medically necessary for any condition or indication.
Policy metadata
Policy NumberCS1O3ID.A
Effective DateJune 1, 2025
State ApplicabilityThis policy applies only to services provided in the state of Idaho, including Idaho Medicaid Plus; providers should ensure Idaho-specific coverage determination is used.
Coverage StanceNot medically necessary for any indication (Platelet-rich plasma and Prolotherapy are unproven and not medically necessary).
Scope SummaryState-specific UnitedHealthcare medical policy (Idaho, including Idaho Medicaid Plus) addressing coverage determination for platelet-rich plasma and prolotherapy injections, with supporting description and evidence review; includes applicable procedure and supply codes for reference.
Medical-Necessity Criteria
Coverage Rationale / Medical Necessity
Due to insufficient evidence of efficacy, the following are unproven and not medically necessary for any condition or indication:
All of the following therapies are considered unproven and not medically necessary
Platelet-rich plasma
Prolotherapy
Provider Actions & Billing Impact
Documentation Required
State-specific applicability
This policy applies only to services provided in the state of Idaho, including Idaho Medicaid Plus; providers should ensure Idaho-specific coverage determination is used.
Idaho, including Idaho Medicaid Plus
Denial Risk
Not medically necessary - PRP and Prolotherapy
Claims for platelet-rich plasma (PRP) and prolotherapy are considered unproven and not medically necessary for any condition or indication per this policy and are subject to denial.
0232T
G0460
Coding (reference)
Procedure codes (reference only)CPT
0232T
Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed.
HCPCS codes (reference only)HCPCS
G0460
Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds/ulcers (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment).
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).
M0076
Prolotherapy.
P9020
Platelet rich plasma, each unit.
Background & Evidence Summary
Prolotherapy (including hypertonic dextrose and related injections) and platelet-rich plasma (PRP) are described as injection-based regenerative or proliferative therapies intended to stimulate healing of connective tissues. PRP is an autologous blood preparation concentrated in platelets and growth factors, but preparations are not standardized and vary widely in platelet and white blood cell content. The available evidence across indications is heterogeneous, includes many small or single-center trials and systematic reviews with mixed or inconsistent results, and overall is limited by variable PRP protocols and study quality. Higher-quality, larger randomized trials with standardized preparation and longer follow-up are needed to determine efficacy and optimal techniques.
Evidence key-value pairs
Overall evidence statementAvailable studies are limited, heterogeneous, often small or biased; insufficient evidence of efficacy to support coverage for any condition.
Major RCT - Bennell et al. (2021) - Knee OAn=288; 3 weekly leukocyte-poor PRP injections vs saline; no difference in symptoms or cartilage volume at 12 months; 29 of 31 secondary outcomes no difference.
Major RCT - Dorio et al. (2021) - Knee OAn=62; PRP vs plasma vs saline (2 injections); no superiority of PRP; higher mild transient pain AEs in PRP group (65%).
Definitions
Term
Definition
Prolotherapy
Injection of substances (e.g., dextrose, saline, sarapin, procaine or lidocaine) to stimulate healing and tissue growth at injured connective tissue sites; includes growth factor injection, growth factor stimulation, and inflammatory prolotherapy.
Platelet-rich plasma (PRP)
An autologous blood preparation with concentrated platelets and growth factors; preparations vary widely and are not standardized.
Dextrose Prolotherapy
DPT
Visual Analog Scale for pain
VAS
Shoulder Pain and Disability Index
SPADI
Western Ontario and McMaster Universities Osteoarthritis Index
WOMAC
Platelet-rich plasma; autologous blood concentrate used for intra-articular or soft tissue injections; preparations vary (leukocyte-rich vs leukocyte-poor).
PRP
Platelet-rich plasma, an autologous blood product concentrated in platelets used as an adjunct or primary therapy in musculoskeletal and wound indications.
Randomized controlled trial
RCT
Diabetic foot ulcer
DFU
Venous leg ulcer
VLU
Revision History
2025-06-01Effective DateLatest
Policy effective date shown
Policy Summary
PayerUnitedHealthcare
PolicyProlotherapy and Platelet Rich Plasma Therapies (for Idaho Only)
Policy CodePolicy CS1O3ID.A
Change TypeNo material change (evidence summary / reaffirmation)
Effective DateJune 1, 2025
Next Review Date
Key ActionClaims for platelet-rich plasma (PRP) and prolotherapy are considered unproven and not medically necessary for any condition or indication per this policy and are subject to denial.
On This Page
G0465
M0076
P9020
Major meta-analysis - Filardo et al. (2021) - Knee OA
34 RCTs; WOMAC favored PRP vs placebo at 12 months and vs HA at 6 and 12 months; quality of evidence low; benefit partial and heterogenous.
Hayes reviews / HTAs (2020-2022)Comparative effectiveness reviews: mixed findings; potential small benefit vs HA at 1 year for knee OA; inconclusive for many indications; heterogeneity limits conclusions.
ECRI assessmentsECRI reports: PRP may yield better WOMAC vs HA/corticosteroids/placebo at 3–12 months for KOA; evidence inconclusive due to heterogeneity and varied PRP protocols.
Tendinopathies evidence (systematic reviews)PRP shows some benefit for patellar and lateral epicondylar tendinopathy; Achilles and rotator cuff evidence mixed or insufficient; overall low/very-low certainty.
Prolotherapy meta-analyses / RCTsProlotherapy studies show some short- to mid-term benefit for knee OA, lateral epicondylosis, TMJ and selected tendinopathies but trials are small, heterogeneous and at high risk of bias.
Wounds - Diabetic Foot Ulcers (DFU)Systematic reviews and RCTs (~1,323 patients): moderate-strength evidence suggests PRP may increase complete wound closure; heterogeneity in protocols.
Wounds - Venous Leg Ulcers (VLUs)RCTs and cohort studies (small) show mixed results; evidence inconclusive due to small studies and heterogeneity.
TMJ prolotherapy evidenceSystematic review/meta-analysis: SMD -0.76 (95% CI -1.19 to -0.32) for pain vs placebo; small trials and risk of bias limit certainty.
Lateral epicondylosis - DPT meta-analysisPooled function at 12 weeks (DASH) MD -15.04 (95% CI -20.25 to -9.82); pooled pain benefit but studies small and short-term.
Knee prolotherapy systematic reviewsSome meta-analyses conclude potential benefit vs exercise or saline in limited trials; overall evidence low quality and heterogenous.
Plantar fasciitis - PRP RCTs/meta-analysesSome RCTs (e.g., Kumar et al. 2024) and meta-analyses (Fei et al. 2021) show PRP may outperform steroids at mid-term follow-up; limited sample sizes.
Achilles / plantar fasciitis - prolotherapyDextrose prolotherapy shows short-term benefit vs non-active controls in several small RCTs/meta-analyses; long-term effects unclear.
PRP for rotator cuff repairMultiple meta-analyses (~13) report lower retear rates and short-term score improvements but evidence is low quality and inconsistent.
Lateral epicondylitis - PRP reviewsSystematic reviews/meta-analyses show mixed results vs steroids/placebo; some long-term benefits reported but heterogeneity limits conclusions.
Meniscal repair / ACLR / patellar tendinopathyMixed and limited evidence: short-term improvements reported in some studies (ACLR), but no consistent long-term benefit; meniscal repair augmentation not proven.
Guidelines consensusMultiple professional guidelines (AAOS, AAHKS, ACR, NICE, VA/DoD) note limited/low-quality evidence and generally recommend against or say insufficient evidence for routine PRP/prolotherapy use in OA and many indications.
Overall conclusion from evidence arrayAcross indications evidence is inconsistent, study designs and PRP/prolotherapy protocols are heterogeneous, and overall quality is low-to-very-low — insufficient to support coverage; higher-quality standardized trials are needed.