NOTE: Medicare does not pay for Prolotherapy or PRP injection procedures. You will have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need.

Medicare does not pay for the following:

Prolotherapy and PRP Injections 

Reason Medicare may not pay: 

Considered by Medicare to be experimental

Cost:

$400-$1,200

  

WHAT YOU NEED TO KNOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• By choosing to sign this document, you agree to the following:
  • Receiving Prolotherapy and or PRP Injections.
  • You understand Medicare will not be billed.
  • You understand Medicare will not reimburse the service rendered.

 

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also received a copy.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131

Form Approved OMB No. 0938-0566