Coverage Rationale Applicable Codes

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Prolotherapy and Platelet Rich Plasma Therapies Page 1 of 24 UnitedHealthcare Commercial Medical Policy Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Medica l Policy Prolotherapy and Platelet Rich Plasma Therapies Policy Number: 2022T0498V Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale ........................................ ............................... 1 Applicable Codes ........................................ .................................. 1 Description of Services ........................................ ......................... 2 Clinical Evidence ........................................ ................................... 2 Food and Drug Administration ........................................ ... 18 References.

Medicare Advantage Coverage Summary • Wound Treatments. ... included 174 articles of which 97 met criteria to assess the benefits and harms of nonsurgical interventional therapies for low back and radicular pain. Of the 97, only 5 addressed prolotherapy. ... determined because the prolotherapy group received strong manipulation and the ...

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