Healthcare Fraud Shield’s Latest Article: What Is Prolotherapy and Is It A Covered Service?

18 Dec

What Is Prolotherapy and Is It A Covered Service?

What Is Prolotherapy?

Prolotherapy involves patients receiving injections into ligaments or tendons to treat pain, typically joint pain.  The injection consists of a dextrose solution, also known as sugar water.  The injection causes an inflammation or swelling to the area.  This increases the blood supply as well as the flow of nutrients stimulating the tissue to repair itself. 

Modern day prolotherapy as well as the term “prolotherapy” is attributed to the works of Dr. George Hackett who began using these injections in 1939. [1] However, according to Prolotherapy.com, this treatment dates back to Hippocrates, who would use prolotherapy “on soldiers with dislocated, torn shoulder joints. He would stick a hot poker into the joint, and it would then miraculously heal normally”. [2]

Is Prolotherapy A Covered Service?

Prolotherapy is typically considered investigational by most payers.  Medicare maintains a National Coverage Determination (NCD) titled “PROLOTHERAPY, JOINT SCLEROTHERAPY, AND LIGAMENTOUS INJECTIONS WITH SCLEROSING AGENTS” which states “The medical effectiveness of the above therapies has not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they are not reasonable and necessary as required by §1862(a)(1) of the Act”.  [3] Other commercial payers such as Health Net consider “Prolotherapy as a treatment of musculoskeletal pain or any other indication, investigational”. [4] 

How Is It Billed?

The appropriate code to use for prolotherapy is HCPCS code M0076.  However, upon using the correct code, most claims for prolotherapy will be denied as investigational or experimental.   As a result, providers trying to defraud insurance companies will often use other procedures codes.    Things to look for in order to identify potential fraud, waste, and abuse:

1)                  Any provider that has ever submitted a claim with M0076 in the past

2)                  Providers billing for trigger point injections using CPT® codes 20552, 20553, but with no corresponding medication such as  a steroid or local anesthetic

3)                  Blue Cross of Idaho notes providers may also be using CPT® codes 20550, 20551, 27096 , 29999 and/or 64475 [5]

As a reminder, please check your respective policies as they apply to prolotherapy services.  If you need any assistance investigating prolotherapy issues, feel free to email us at info@hcfraudshield.com.

 

[1] CMS Decision Memo

[2] Prolotherapy.com

[3] CMS NCD

[4] Health Net Policy

[5] Blue Cross of Idaho Policy

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