Does Medicare Cover Prolotherapy Treatment?

Prolotherapy, also known as proliferation therapy or regenerative injection therapy, involves injecting an irritant solution, often dextrose, into injured connective tissues like ligaments and tendons to stimulate the body’s natural healing processes. Many individuals experiencing chronic musculoskeletal pain consider this treatment to alleviate discomfort and improve function. A common question is whether Medicare covers prolotherapy, which involves specific policy guidelines. This article clarifies Medicare’s position on prolotherapy and guides you on navigating coverage questions.

Medicare’s Policy on Prolotherapy Coverage

Medicare generally considers prolotherapy an experimental or investigational treatment, meaning it typically does not provide coverage for the procedure. This classification stems from a lack of widespread scientific evidence to verify its medical effectiveness and safety through controlled studies. As a result, the treatment is not considered “reasonable and necessary” under Medicare’s guidelines.

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), primarily covers services deemed medically necessary and approved by established medical standards. Since prolotherapy is an outpatient procedure, it would fall under Part B if covered. However, Part B generally does not cover experimental treatments or those lacking sufficient evidence of efficacy. Prolotherapy has maintained its experimental classification since at least 1999 due to insufficient scientific data.

Medicare Advantage (Part C) plans are offered by private companies approved by Medicare, and they are required to cover at least the same benefits as Original Medicare. While these plans might offer additional benefits, their coverage for experimental treatments like prolotherapy remains highly unlikely for the same reasons as Original Medicare. The underlying classification of prolotherapy as investigational typically prevents coverage across all Medicare types.

Confirming Your Specific Medicare Coverage

To determine if your Medicare plan covers prolotherapy, gather information. Begin by discussing the planned treatment with your healthcare provider and ask for the specific Current Procedural Terminology (CPT) codes they intend to use for the prolotherapy injections. There isn’t a specific CPT code for prolotherapy. A HCPCS code M0076 exists, but Medicare does not recognize HCPCS codes in the “M” range. Your provider might use an unlisted procedure code, such as 20999, or a comparison code like 20550, which describes an injection into a tendon or ligament.

Once you have the relevant codes, contact your Medicare plan directly. If you have Original Medicare, you can call 1-800-MEDICARE (1-800-633-4227). If you are enrolled in a Medicare Advantage plan, locate the customer service number on your plan membership card and contact your specific provider. When speaking with a representative, clearly state the CPT or HCPCS code and ask if it is covered for your specific diagnosis. Inquire about any medical necessity criteria that must be met and whether prior authorization is required. Document the conversation, including the date, representative’s name, and what was discussed, and request any coverage information in writing if possible.

Next Steps If Prolotherapy is Not Covered

If prolotherapy is not covered by your Medicare plan, consider these next steps. Your healthcare provider should issue an Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, before providing the service. This notice informs you that Medicare is not expected to cover the service and that you will be financially responsible for the costs if you choose to proceed. Signing the ABN indicates your understanding and acceptance of potential financial liability.

You retain the right to appeal Medicare’s coverage decision if you believe it is incorrect. The appeal process involves multiple levels, typically starting with a redetermination by a Medicare administrative contractor. While an appeal is an option, successfully challenging a denial based on a treatment being deemed experimental can be difficult due to the lack of recognized scientific evidence supporting coverage.

Alternatively, discuss with your doctor other pain management treatments that Medicare does cover, such as physical therapy, occupational therapy, or certain injections for specific conditions, which are considered medically necessary. If you still wish to pursue prolotherapy despite non-coverage, self-pay remains an option. The national average cost for one prolotherapy injection can range from approximately $150 to $200, with multiple sessions typically required.