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.

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         

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

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.