Prolotherapy and Sclerotherapy (CPB 0207, reviewed 2026-03-27)

By 2026-03-27: Billing team must immediately flag and DENY all claims for prolotherapy (CPT 20550, 20600-20611, HCPCS M0076) regardless of diagnosis code—these procedures are now classified as experimental/investigational for ALL indications and are not covered. For sclerotherapy claims (CPT 36465, 36466, 36468, 36470, 36471, 43204, 43243, 45520, 49185): Update billing system validation rules to require diagnosis code verification against the covered indications list (esophageal varices, aneurysmal bone cysts, thyroid nodules, epistaxis from hereditary hemorrhagic telangiectasia, Morton's neuroma, pediatric rectal prolapse, hemorrhoids, lymphatic malformations, orbital varices, renal cysts 3-20cm, testicular hydrocele, venous malformations, venous ulcerations, hepatic cysts ≥4cm). Reject claims with non-covered diagnosis codes (e.g., achilles tendinopathy M76.60-M76.62, knee osteoarthritis M17.0-M17.9, plantar fasciitis M72.0-M72.9, epicondylitis M77.00-M77.12). Do NOT process sclerotherapy for prophylaxis of esophageal variceal bleeding—only active hemorrhage. Update provider communication templates to include this comprehensive list of covered vs. non-covered indications. Consequences: Claims submitted outside covered indications will be denied; providers may face post-payment audits for previously paid experimental procedures.