Payer PolicyActive
CMM-204: Prolotherapy
EVICORE-MSK_ADVANCED-69D71E74
EviCore by Evernorth
Effective: July 1, 2021
Updated: January 13, 2026
created · Dec 5, 2025
Policy Summary
Prolotherapy for musculoskeletal pain and/or instability is considered experimental, investigational, or unproven and is not supported for coverage. Evidence is inconclusive, the treatment may cause serious adverse events, CPT code M0076 is listed as EIU, and final reimbursement/prior authorization decisions rest with the individual health plan and policy.
Coverage Criteria Preview
Key requirements from the full policy
"Prolotherapy performed for the treatment of musculoskeletal pain and/or instability (e."
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