Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for ultrasound guided dextrose prolotherapy (CPT codes 20550, 76942 x1, J3490 x6 and J2001 x1). The enrollee has a diagnosis of right-sided tibialis posterior tendinitis. She has left knee pain from osteoarthritis. An ultrasound demonstrated increased mixed echogenicity of the right posterior tibialis tendon. There was significant fluid around the right posterior tibialis tendon. The enrollee received a right posterior tibialis tendon sheath Toradol injection. The injection helped her pain. She reportedly only experienced pain when running and with high impact activities, which she has avoided. The surgeon suggested a dextrose injection for pain management as the enrollee has failed conservative treatment. Literature notes dextrose proliferant has been approved for injection by governmental bodies, but not for prolotherapy; thus, it is currently used in prolotherapy as an off-label substance. The mechanism of action behind prolotherapy is not completely understood. However, current theory holds the injected proliferant mimics the natural healing process of the body by initiating a local inflammatory cascade, which triggers the release of growth factors and collagen deposition. This study supports prolotherapy for tendinopathies. However, the evidence rating is specific to the studies that they were able to evaluate. None of these studies has evaluated its use for posterior tibialis tendon issues. The enrollee was previously treated with a Toradol injection to the right posterior tibialis tendon, from which the enrollee experienced relief.  Published studies on prolotherapy, using randomized control trials and demonstrating high levels of evidence, are becoming more common. However, most literature consists of non-randomized prospective controlled trials, cohort studies, case control series, case series, or single-subject case reports. Furthermore, no recent systematic review has been published that solely addresses the efficacy of dextrose prolotherapy for multiple areas of chronic musculoskeletal pain with data from randomized control trials. A systematic review suggests prolotherapy may be associated with symptom improvement in mild to moderate knee osteoarthritis and overuse tendinopathy. This literature suggests it may be appropriate, but does not state that it is, or would be, beneficial. Literature notes the dextrose concentrations used for treatment are anecdotally, rather than empirically, derived over decades of use by physicians who practice prolotherapy. Researchers have assessed prolotherapy for six overuse tendon disorders: lateral epicondylosis, Achilles tendinopathy, Osgood-Schlatter disease, rotator cuff and hip adductor tendinopathies, and plantar fasciopathy. However, researchers have not studied prolotherapy treatment for posterior tibialis tendon tear/tendinopathy. Based on the available literature, strong evidence advocating for use of prolotherapy is lacking for tendinopathy. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.