CMM-204: Prolotherapy

Cigna/eviCore CMM-204 (effective July 1, 2025) designates prolotherapy for musculoskeletal pain/instability as experimental, investigational, or unproven and therefore not covered under this policy due to inconclusive evidence of clinical efficacy. No specific documentation or prior‑authorization requirements are listed; coverage and payment are determined by the member’s applicable benefit plan and any applicable laws/regulations, which supersede this policy.

"Prolotherapy performed for the treatment of musculoskeletal pain and/or instability (e."

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