CurrentunitedhealthcarePolicy CS103OH.C

Prolotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

This Ohio-only medical policy governs coverage determinations for prolotherapy and platelet-rich plasma (PRP) therapies, lists applicable procedure and supply codes for reference, provides clinical rationale and evidence summaries, and indicates that these therapies are considered unproven and not medically necessary for any condition.

Policy Summary

Payerunitedhealthcare

PolicyProlotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

Policy CodePolicy CS103OH.C

Change TypeRevised — supporting evidence and references updated

Effective DateMar 1, 2026

Next Review Date

Key ActionFor Ohio requests, providers should expect evaluation of medical necessity using Ohio Administrative Code 5160-101 and include documentation supporting medical necessity when submitting requests.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information.

2Therapies designated not medically necessary

5Procedure / supply codes referenced

heterogeneousIntervention heterogeneity

low-to-very-lowOverall evidence quality

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multipleIndications reviewed

Coverage Summary

Overview (UnitedHealthcare Policy CS103OH.C — Ohio only): This Ohio‑only medical policy (Policy Number CS103OH.C, effective March 1, 2026, last reviewed March 1, 2026) from UnitedHealthcare addresses coverage for prolotherapy and platelet‑rich plasma (PRP) therapies. The policy applies only to services in the state of Ohio and references Ohio Administrative Code 5160‑101 for medical necessity evaluation. The policy conclusion based on the evidence is that, due to insufficient evidence of efficacy, prolotherapy and platelet‑rich plasma are considered unproven and not medically necessary for any condition or indication and claims for these services in Ohio are subject to denial under this policy.

Policy at-a-glance

PolicyMedical Policy (CS103OH.C)

PayerUnitedHealthcare

Effective Date2026-03-01

Last Review2026-03-01

ScopeOhio only

Coverage ConclusionProlotherapy & PRP — unproven and not medically necessary for any condition

Referenced procedure/supply codes0232T, G0460, G0465, M0076, P9020

Medical Necessity Determinations

Provider Actions & Authorization Implications

Denial Risk

Claims considered not medically necessary and subject to denial (Ohio)

Claims for prolotherapy and platelet-rich plasma (PRP) therapies in Ohio are considered not medically necessary and are subject to denial. Submitters should expect denials for routine prolotherapy and PRP injection claims unless there is clear, contract- or state-required justification that overrides the policy determination.

Relevant codes: 0232T; G0460; G0465; M0076; P9020. See Applicable Codes section for full descriptions.

Documentation Required

Evidence limitations and required documentation for PRP

Evidence for prolotherapy and PRP is limited and heterogeneous. When submitting documentation for PRP, include preparation and procedural variables that affect interpretation of outcomes: platelet concentration, total volume injected, leukocyte content (leukocyte-rich vs leukocyte-poor), whether activation was used (and method), and detailed injection technique and anatomic target.

Procedure & Supply Codes (Reference)

Reference procedure and supply codes listed in policymixed

0232T	Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
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

Reference codes (for informational use only): The listed procedure and supply codes (e.g., 0232T, G0460, G0465, M0076, P9020) are provided for reference only; inclusion does not imply coverage. Claims for these codes when submitted for prolotherapy or PRP indications in Ohio are subject to denial per this policy and will be evaluated under the Ohio‑specific medical necessity standard.

Background & Definitions

Background: Prolotherapy describes injections of substances (for example, hypertonic dextrose, saline, sarapin, procaine, lidocaine) intended to stimulate local healing of ligaments, tendons, or joints by provoking a mild inflammatory response and tissue repair. Platelet‑rich plasma (PRP) is an autologous blood product with concentrated platelets, growth factors, and cytokines that may stimulate regeneration. Both prolotherapy and PRP lack standardized preparation methods and protocols; PRP preparations vary widely in platelet and white blood cell content and delivery methods. Because of this heterogeneity in preparations, dosing, and techniques, clinical study results are variable and difficult to generalize.

Term	Definition
ASAM
American Society of Addiction Medicine criteria used for substance use administration; UnitedHealthcare uses ASAM for substance use decisions.

Evidence Overview

Evidence summary — high level: The policy concludes these therapies are unproven and not medically necessary because the available studies are generally limited, heterogeneous, and of low to very low overall quality. The evidence base includes many small randomized trials, observational studies, and multiple systematic reviews and technology assessments (Hayes, ECRI) that report mixed results across indications. Key limitations across studies are small sample sizes, inconsistent or short follow‑up, variable and nonstandardized PRP/prolotherapy preparations and injection protocols, and inconsistent adverse event reporting. While some trials and meta‑analyses report short‑ or mid‑term symptom improvement for select indications (for example, certain tendinopathies or plantar fasciitis), larger rigorous randomized trials often show no meaningful benefit (e.g., knee OA trials) and meta‑analyses note low certainty. A notable safety signal identified in foot/ankle RCTs and pooled analyses is higher rates of post‑injection pain and complications with PRP versus comparators (Fucaloro 2025), with an estimated number needed to harm of 13 for any complication in pooled studies. Overall, evidence heterogeneity and methodological limitations preclude definitive conclusions and underscore the need for larger, high‑quality randomized controlled trials with standardized PRP/prolotherapy protocols, longer follow‑up, and consistent adverse event reporting before routine coverage can be supported.

Selected evidence metrics

Policy conclusionInsufficient evidence of efficacy; therapies considered unproven and not medically necessary for any condition.

Overall evidence qualityLow-to-very-low; heterogeneous, small RCTs and systematic reviews

Revision History

2026-03-01Summary of ChangesLatest

Updated Clinical Evidence and References sections; previous policy version CS103OH.B archived.

Policy Summary

Payerunitedhealthcare

PolicyProlotherapy and Platelet Rich Plasma Therapies (for Ohio Only)

Policy CodePolicy CS103OH.C

Change TypeRevised — supporting evidence and references updated

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

Document PRP preparation method (centrifugation steps, device used) and final platelet and leukocyte counts when available.
Record activation status (e.g., calcium chloride, thrombin) and exact injection site(s) and guidance (e.g., ultrasound).

Prior Authorization

Prior authorization implications (informational)

Prior authorization may be required for PRP or prolotherapy procedures. Payers may request review and clinical justification prior to payment due to limited and inconsistent evidence and the policy determination that these therapies are unproven.

If prior authorization is requested or required, include documentation of prior conservative therapy trials and objective measures of failure.
Justification should reference the limited evidence base and specific clinical rationale for exceeding usual coverage expectations.

Documentation Required

State- and contract-specific medical necessity evaluation (Ohio)

When requesting medical necessity review or prior authorization in Ohio, reference state rules and contract terms. Requests should cite Ohio Administrative Code 5160-101 and any applicable federal or contractual requirements that may affect coverage decisions.

Include contract citations or member-specific benefit language when applicable.
Reference Ohio Administrative Code 5160-101 as the basis for state-specific medical necessity evaluation.

Denial Risk

Denial risk for routine PRP/prolotherapy

Routine PRP injection claims may be denied or may require additional clinical information and justification. Comparative effectiveness across indications is inconsistent; therefore routine use without robust supporting evidence or appropriate prior conservative therapy trials risks denial.

Denial risk applies to CPT 0232T and related PRP/prolotherapy procedure and supply codes listed in the Applicable Codes section.
Provide objective clinical measures and documentation of failed conservative treatments to reduce denial risk.

Documentation Required

Use of InterQual / guidelines and PA dependence on contract/state rules

Operational guidance for utilization review: InterQual, ASAM, or other evidence-based guideline criteria may be used to inform coverage and prior authorization decisions. Whether PA is required depends on the member's contract and applicable state rules.

Use InterQual (when applicable) or other specialty guidelines as part of utilization management determinations.
Prior authorization requirement is dependent on payer contract language and Ohio regulatory requirements; always verify specific plan terms.

Prior Authorization

Policy may inform prior authorization requirements

The policy content may be used to inform prior authorization criteria and operational workflows. Where PA programs exist, this policy supports requiring documentation of prior conservative management, indication-specific justification, and the PRP preparation details described above.

PA reviewers may require failure of appropriate conservative therapies and objective outcome measures prior to approval.
Policy determinations do not replace plan contract language or state/federal mandates; approvals should align with applicable regulatory and contractual obligations.

Reported safety signal (foot/ankle)Meta-analysis (Fucaloro 2025) found higher post-injection pain and overall complications with PRP in foot/ankle (NNH=13).

Hayes C rating for DFUHayes assigned a C rating: low-quality evidence suggests PRP may be safe and potentially improve healing in hard-to-heal diabetic foot ulcers as adjunct to conventional wound therapy.