Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Coverage decision: Not Covered (Effective date: February 1, 2020)
Perineural injection therapy (PIT), aka neural prolotherapy, neurofascial prolotherapy, perineural subcutaneous prolotherapy, perineural deep injection and perineural subcutaneous injection, is not a covered benefit for any indication. The procedure has not been proven safe and effective in high quality peer reviewed studies. In addition, the Department does not cover prolotherapy (WAC 296-20-03002). PIT is considered a form of prolotherapy.
PIT involves the injection of a dextrose solution (typically 5%), with or without an anesthetic agent, into tender points in the subcutaneous tissue along the path of the affected nerve or into the peripheral nerve for management of chronic pain, such as neurogenic pain, carpal tunnel syndrome and low back pain.
Perineural injection therapy should not be confused with peripheral nerve blocks (e.g., CPT® code 64450), which are allowed for regional anesthesia and acute pain management.
Regulatory authority and related information