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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.

Listing of a code in this policy does not imply that the service described by the code is a covered or non- covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may ... UnitedHealthcare Commercial Medical Policy Effective 01/01/2022 .

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