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DESCRIPTIONProlotherapy describes a procedure intended for healing and strengthening ligaments and tendons by injecting an agent that induces inflammation and stimulates endogenous repair mechanisms. Although this treatment is similar to sclerotherapy for varicose veins, the goal of prolotherapy is to promote tissue repair or growth by prompting release of growth factors, such as cytokines, or increasing the effectiveness of existing circulating growth factors. The mechanism of action is not well understood, but may involve local irritation and/or cell lysis. Prolotherapy may also be referred to as proliferant injection, prolo, joint sclerotherapy, regenerative injection therapy, growth factor stimulation injection, or nonsurgical tendon, ligament and joint reconstruction.Agents used with prolotherapy have included zinc sulfate, psyllium seed oil, combinations of dextrose, glycerine, and phenol, or dextrose alone, often combined with a local anesthetic. Polidocanol and sodium morrhuate, vascular sclerosants, have also been used to sclerose areas of high intratendinous blood flow associated with tendinopathies. Prolotherapy typically involves multiple injections per session conducted over a series of treatment sessions.
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POLICYProlotherapy is considered investigational as a treatment of musculoskeletal pain.Sarapin, an herbal extract, that has been used as a sclerosant in prolotherapy, is considered investigational.
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POLICY EXCEPTIONSNone
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POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY6/1997: Approved by Medical Policy Advisory Committee (MPAC)1/24/2001: Non-covered codes table added, HCPCS M0076 added non-covered codes 2/2001: Reviewed by MPAC; investigational status maintained 3/1/2001: Source(s) section updated 5/22/2001: ICD-9 procedure code 99.29 added non-covered codes 2/11/2002: Investigational definition added 5/2/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, ICD-9 procedure code 81.92 added non-covered codes 11/18/2004: Reviewed by MPAC, Prolotherapy remains investigational, sarapin, an herbal extract, that has been used as a sclerosant in prolotherapy, is considered investigational. 7/19/2005: Code Reference section reviewed, no changes 8/14/2009: Policy reviewed, no changes 09/09/210: Policy description updated regarding treatment approaches. Policy statement unchanged. 09/23/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes.
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SOURCE(S)Blue Cross & Blue Shield Association policy #2.01.26
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CODE REFERENCEThis is not an all-inclusive list of non-covered procedure codes.All codes billed for this procedure are considered investigational and not eligible for coverage. Non-Covered Codes
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