CMM-204: Prolotherapy

Prolotherapy (CPT M0076) is considered experimental, investigational, and unproven for musculoskeletal pain or instability (cited due to lack of conclusive evidence and potential adverse effects) and is not covered. No covered ICD‑10 diagnoses or documentation requirements are provided; final reimbursement/authorization is determined by the individual health plan’s benefit and claims rules.

"None. The guideline does NOT identify any covered indications."

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