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Medical Policy: 02.01.18
Original Effective Date: November 1996
Reviewed: August 2011
Revised: July 2001
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Prolotherapy refers to a procedure performed to strengthen the lax or injured ligaments by injecting proliferating agents/sclerosing solutions directly into torn or stretched ligaments. It is proposed that prolotherapy, over a period of a few weeks, may relieve pain in the affected area, with a return to normal function of the associated painful articulation.
Prolotherapy may involve a single or a series of injections of the proliferating agent, which are often diluted with a local anesthetic. Agents used for prolotherapy include zinc sulphate, psyllium seed oil, hypertonic glucose, and phenol or carbolic acid at times mixed with glycerol.
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Prior Approval:
Not applicable
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Policy:
Prolotherapy is considered investigational for all applications.
The literature consists of small randomized trials on a variety of pain syndromes with inconsistent results. The body of scientific evidence does not permit conclusions concerning the effect of prolotherapy on health outcomes for chronic neck or back pain, tendinopathies of the upper or lower limbs, osteoarthritic pain, or other musculoskeletal pain conditions.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- HCPCS M0076 should be used for reporting prolotherapy. The code includes the charges for proliferatives.
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Selected References:
- Medicare Coverage Issue Manual, 35-13. Prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agents- not covered.
- Reeves, K.D., Hassanein, K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: Evidence of clinical efficacy. The Journal of Alternative and Complementary Medicine 2000; vol 6, No 4: 311-320.
- Reeves, K.D., Hassanein, K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. The Journal of Alternative and Complementary Medicine 2000; vol 6, No.2: 68-7.
- Hauser, R.A. Punishing the pain - Treating chronic pain with prolotherapy. Rehab Management Feb/March 1999;26-30.
- Dechow E, Davies RK, Carr AJ, Thompson PW. A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. Rheumatology (Oxford) 1999 Dec;38(12):1255-9.
- Tsatsos G, Mandal R. Prolotherapy in the treatment of foot problems. J Am Podiatr Med Assoc 2002 Jun;92(6):366-8.
- ECRI. Prolotherapy for ligament or tendon pain. Plymouth meeting (PA): ECRI Health technology Information Service; 2004 May 14. 8 p. (ECRI Hotline Response). Also available: http//www.ecri.org.
- Linetsky, F. S., Miguel, R., and Torres, F. Treatment of cervicothoracic pain and cervicogenic headaches with regenerative injection therapy. Curr Pain Headache Rep. 2004;8(1):41-8.
- Kim WM, Lee HG, Jeong CW et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med 2010; 16(12):1285-90.
- Scarpone M, Rabago DP, ZZgierska A et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med 2008; 18(3):248-54.
- Rabago D, Best TM, Zgierska A et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. Br J Sports Med 2009; 43(7):471-81.
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Policy History:
Date Reason Action
August 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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