Prolotherapy

This policy addresses prolotherapy (including intra‑articular dextrose injections) and the use of sclerosing agents for venous conditions as treatments for musculoskeletal pain, osteoarthritis, tendinopathies, sacroiliac joint pain, and spider/varicose/esophageal varices. Major limitations: sclerosing agents are FDA‑approved only for telangiectasias/varicose veins and esophageal varices—not for intra‑articular or ligamentous use; prolotherapy for musculoskeletal pain is considered experimental/investigational (not supported as a standalone treatment for chronic low back pain); coverage is subject to the member’s benefit plan and certain indications (e.g., SI‑joint treatment) may require a positive diagnostic anesthetic block or arthrographic confirmation.

"Treatment of spider veins (telangiectasias) with FDA‑approved sclerosing agents"

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