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Effective Date: 09/18/2004 |
Title: Prolotherapy
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Revision Date: 04/29/2004
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Document: BI030:00
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CPT Code(s): M0076
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Public Statement
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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.
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Medical Statement
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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
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Reference
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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
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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