Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-193
Topic: Prolotherapy
Effective Date: October 29, 2007
Issued Date: August 31, 2009
Date Last Reviewed: 07/2009

General Policy Guidelines

Indications and Limitations of Coverage

Prolotherapy is considered investigational as a treatment of musculoskeletal pain and, therefore, is not covered. Scientific evidence does not demonstrate the efficacy of the service. A participating, preferred, or network provider can bill the member for the denied service.

Description

Prolotherapy describes a procedure for strengthening lax ligaments by injecting proliferating agents/sclerosing solutions directly into torn or stretched ligaments or into a joint or adjacent structures to create scar tissue in an effort to stabilize a joint. Agents used with prolotherapy have included zinc sulfate, psyllium seed oil, combinations of dextrose, glycerine, and phenol, or dextrose alone. "Proliferatives" act to promote tissue repair or growth by prompting release of growth factors, such as cytokines, or increasing the effectiveness of existing circulating growth factors. Prolotherapy may involve a single injection or a series of injections, often diluted with a local anesthetic.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

M0076     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Intraligamentous Injection of Sclerosing Solutions (Prolotherapy) for Spinal Pain: A Critical Review of the Literature, Spine, Vol. 5, Issue 3, May-June 2005

Side Effects and Adverse Events Related to Intraligamentous Injection of Sclerosing Solutions (Prolotherapy) for Back and Neck Pain: A Survey of Practitioners, Arch Phys Med Rehabil, Vol. 87, Issue 7, July 2006

Prolotherapy Injections for Chronic Low-Back Pain, Cochrane Database Syst Rev, Vol. 18, Issue 2, April 2007

A Systematic Review of Prolotherapy for Chronic Musculoskeletal Pain, Clinical Journal of Sports Medicine, Vol. 15, Issue 5, September 2005

Defining Worthwhile and Desired Responses to Treatment of Chronic Low Back Pain, Pain Medicine, Vol. 7, Issue 1, January-February 2006

National Blue Cross Blue Shield Association Medica Policy 2.01.26, Prolotherapy, 07/2008

Scarpone M. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008 May; 18(3):248-54

Khan SA; Kumar A; Vashney MK; Trikha V; Yadav CS. Dextrose prolotherapy for recalcitrant coccygodynia. J Orthop Surg (Hong Kong). 2008 Apr; 16(1): 27-29

Staal JB. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine. 2009 Jan; 34(1): 49-59

Dagenais S. Evidence-Informed Management of Chronic Low Back Pain with Prolotherapy. Spine J. 2008 Jan; 8(1): 203-212

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Table Attachment

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Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.