Coverage Rationale Applicable Codes

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 .. 18 Policy History/Revision Information .. 23 Instructions for Use .. 23 Coverage Rationale Due to insufficient evidence of efficacy, the following are unproven and not medically necessary for any condition or indication: Prolotherapy Platelet-Rich Plasma Note: Refer to the Medical Policy titled Skin and Soft Tissue Substitutes for information related to amnion-derived fluid injections/therapy.

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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