CMM-204: Prolotherapy

Prolotherapy for treatment of musculoskeletal pain or instability is classified as experimental, investigational, or unproven (EIU) and has no covered indications. The policy specifies no documentation or coverage requirements, notes that listing code M0076 does not imply coverage or guarantee payment, and that benefit eligibility is determined by the member’s plan Certificate/Evidence of Coverage.

"No covered indications identified. (The document contains no 'Covered Indications' section and does not state any Medicare-covered uses."

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