M0076 ProlotherapyProlotherapy
Status N: non-covered service.
4 of 4 payer prior-auth lists that name M0076 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | eviCore-managed | Jan 1, 2020 | Procedure Code List, Effective 1/1/2025 |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 |
M0076 appears in 22 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, BlueCross BlueShield of South Carolina, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Prolotherapy and Sclerotherapy (0207) | not covered | Mar 27, 2026 | payer document |
| Aetna | Temporomandibular Disorders (0028) | not covered | Mar 12, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Prolotherapy | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Prolotherapy | not covered | Nov 20, 2025 | payer document |
| Blue Cross Blue Shield of Massachusetts | prolotherapy (183) | unproven / investigational | payer document | |
| Blue Shield of California | | Prolotherapy (2.01.26) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Prolotherapy (CAM 20126) 27096 | Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid | listed, no stance | May 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Prolotherapy (MED201.013) | listed, no stance | Jun 15, 2025 | payer document |
| Premera Blue Cross | Prolotherapy (2.01.26) | listed, no stance | Jan 12, 2026 | payer document |
| Regence | Prolotherapy (Medicine 40) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (CS103.V) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (2026T0498CC) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Idaho Only) (CS103ID.B) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Kansas Only) (CS103KS.02) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Kentucky Only) (CS103KY.08) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Nebraska Only) (CS103NE.V) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for New Jersey Only) (CS103NJ.T) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for New Mexico Only) (CS103NM.C) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for North Carolina Only) (CSNCT0498.05) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Ohio Only) (CS103OH.C) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Pennsylvania Only) (CS103PA.S) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Prolotherapy and Platelet Rich Plasma Therapies (for Tennessee Only) (CS103TN.T) | listed, no stance | Feb 1, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.