Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 09/18/2004	Title: Prolotherapy
Revision Date: 04/29/2004	Document: BI030:00
CPT Code(s): M0076
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agent are not a covered benefit. These therapies are not generally accepted as medically necessary treatments. Their medical effectiveness has not been verified by scientifically controlled studies and is therefore considered investigational and experimental.
Medical Statement
Prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agent are not a covered benefit. These therapies are not generally accepted as medically necessary treatments. Their medical effectiveness has not been verified by scientifically controlled studies and, therefore, is considered investigational and experimental. Experimental and Investigational treatments are a specific exclusion in all of our plan documents; therefore these therapies are considered to be contract exclusion. Note: There is no Hayes technology assessment of Prolotherapy available. However, the HCPCS book lists M0076 as a non-covered code. Codes Used In This BI: M0076
Reference
HCFA Coverage Issues Manual, Medical Procedures, #35-13 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents, http://www.hcfa.goc/pubforms/06_cim/ci35.htm
Application to Products
Unless indicated otherwise, this policy applies to all QCA Health Plans, in the absence of a stated exclusion. Consult individual plan sponsor benefit descriptions for self-insured plans. In the event of a discrepancy between this policy and a self-insured customer’s benefit description, the benefits plan will be followed. Applicable state mandates will be followed with respect to self-funded non-ERISA plans and fully insured plans. Federal mandates will apply to all plans.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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