CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Extracorporeal Shock Wave Therapy (ESWT) — Coverage Criteria

This policy governs use and coverage of extracorporeal shock wave therapy (ESWT), including focused and radial devices, for treatment of various musculoskeletal and neurologic conditions for Blue Cross Blue Shield - Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyExtracorporeal Shock Wave Therapy (ESWT) — Coverage Criteria

Policy CodePolicy N/A

Change TypeCoverage stance and investigational determinations summarized

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification/preauthorization when ESWT is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

Outpatient ESWT is listed as not a covered service for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue.

ESWT (focused or radial, high- or low-dose) is investigational for multiple musculoskeletal conditions including plantar fasciitis, stress fractures, avascular necrosis of the femoral head, tendinopathies (shoulder, Achilles, lateral epicondylitis, patellar), delayed union/nonunion, and spasticity.

Precertification/preauthorization is required when the procedure is performed inpatient.

multiple RCTsevidence sources

Not coveredoutpatient coverage

Insufficientindications concluded

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>=7conditions discussed

Coverage Determinations and Evidence Summary

Investigational or not covered indications

Policy coverage stance and investigational determination

Investigational indications: Extracorporeal shock wave therapy (ESWT), using either a high- or low-dose protocol or radial ESWT, is investigational as a treatment of musculoskeletal conditions including but not limited to plantar fasciitis; stress fractures; avascular necrosis of the femoral head; tendinopathies (shoulder, Achilles, elbow/lateral epicondylitis, patellar); delayed union and nonunion of fractures; and spasticity.

Outpatient coverage statement: Outpatient ESWT is not a covered service for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue.

Evidence-based coverage conclusions (insufficient evidence)

Coverage conclusions summarized by indication:

Achilles tendinopathy: Evidence includes systematic reviews and RCTs with inconsistent and heterogeneous results; overall evidence is insufficient to determine improvement in net health outcome.

Short- and long-term pain reductions reported in pooled analyses but inconsistency across trials noted.

Patellar tendinopathy: Systematic reviews and RCTs report inconsistent results and heterogeneous protocols and follow-up durations; evidence is insufficient to determine improvement in net health outcome.

Medial tibial stress syndrome: A small RCT showed no difference and a small nonrandomized study had selection bias; evidence is insufficient to determine improvement in net health outcome.

Osteonecrosis of the femoral head: Systematic reviews of small, mostly nonrandomized studies with heterogeneous protocols and populations; evidence is insufficient to determine improvement in net health outcome.

Nonunion/delayed union and acute long bone fractures: Systematic reviews, small RCTs, and case series with methodologic limitations and heterogeneity; evidence does not permit conclusions on efficacy.

Spasticity: RCTs and systematic reviews (stroke, cerebral palsy) show some improvements in spasticity measures but small sample sizes and methodological limits; evidence is insufficient to determine clinically meaningful improvements in pain or function.

More well-designed trials needed.

For outpatient settings, ESWT (extracorporeal shock wave therapy) is not a covered service for the listed product lines: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue. This noncoverage applies to outpatient delivery of the services described in this policy.

No additional explicit exclusion criteria are specified in the provided document excerpts beyond the outpatient noncoverage statement; the policy excerpts reviewed do not list other categorical exclusions.

Across multiple musculoskeletal conditions — including plantar fasciitis, lateral epicondylitis (tennis elbow), shoulder tendinopathy, Achilles tendinopathy, and patellar tendinopathy — the evidence base consists of numerous randomized controlled trials and several systematic reviews and meta-analyses. Results are heterogeneous: some pooled analyses report short-term pain reduction or functional improvement, while others show no significant benefit. Differences in trial quality and substantial heterogeneity in ESWT protocols (focused versus radial, low- versus high-energy, number of shocks and treatments, and comparators) limit conclusions. Overall, the evidence is judged insufficient to determine that ESWT improves net health outcomes for these indications.

For several specific indications the policy finds the available evidence inadequate to support clinical benefit. These include Achilles tendinopathy and patellar tendinopathy (systematic reviews and RCTs with inconsistent and heterogeneous results), medial tibial stress syndrome (small RCT with no difference and a nonrandomized study with selection bias), osteonecrosis of the femoral head (mostly small, nonrandomized studies with heterogenous protocols), nonunion or delayed union of fractures (systematic reviews, small RCTs, and case series with methodological limitations), and spasticity (small RCTs and reviews showing some changes in spasticity measures but insufficient evidence of clinically meaningful pain or functional improvement). The policy characterizes the evidence for these indications as insufficient to determine improvement in net health outcomes.

Procedure and Billing Codes

Investigational CPT Codes (Commercial Members)CPTNot Covered

28890	Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia.
0101T	Extracorporeal shock wave involving musculoskeletal system, not otherwise specified,high energy.
0102T	Extracorporeal shock wave therapy; high energy, performed by a physician, requiring

Coding informationmixed

No codes listed

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Preauthorization Required for Inpatient Procedures

For services described in this policy, precertification/preauthorization is required for all products if the procedure is performed inpatient.

Applies to all product lines when the procedure is performed in an inpatient setting.

Prior Authorization

Outpatient Coverage and Authorization

For services described in this policy, outpatient extracorporeal shockwave therapy (ESWT) is listed as not a covered service for certain products. Providers should verify member-specific benefits and prior authorization requirements for outpatient procedures based on the member's contract.

Commercial Managed Care (HMO and POS), Outpatient = Not a covered service
Commercial PPO and Indemnity, Outpatient = Not a covered service
Medicare HMO, Outpatient = Not a covered service
Medicare PPO, Outpatient = Not a covered service

Background on ESWT

Extracorporeal shock wave therapy (ESWT) is a noninvasive treatment that delivers externally applied shock waves to musculoskeletal tissues. Devices and protocols vary: focused ESWT sends medium- to high-energy single pressure pulses targeted to a specific site (often using ultrasound or radiographic guidance), while radial ESWT (RSW) transmits lower- to medium-energy shockwaves over a broader surface area. Proposed mechanisms include disruption of calcific deposits, modulation of pain pathways, and stimulation of tissue healing (eg, angiogenesis and osteogenesis), although precise mechanisms are not well defined.

Definitions and Device Types

Focused ESWT — definition and key points

DefinitionFocused ESWT: sends medium- to high-energy shockwaves of single pressure pulses directed at a specific target using ultrasound or radiographic guidance.

Energy levelMedium- to high-energy (single pressure pulses lasting microseconds)

TargetingDelivered to a specific target under ultrasound or radiographic guidance

Regulatory noteFDA approval for focused ESWT devices first granted in 2002.

Radial ESWT (RSW) — definition and key points

DefinitionRadial ESWT (RSW): transmits low- to medium-energy shockwaves radially over a larger surface area.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyExtracorporeal Shock Wave Therapy (ESWT) — Coverage Criteria

Policy CodePolicy N/A

Change TypeCoverage stance and investigational determinations summarized

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification/preauthorization when ESWT is performed inpatient.

SourceLink

On This Page

Step Therapy

Conservative Therapy Preceding Consideration

Conservative therapies should be tried before consideration of procedures discussed in this policy. Typical conservative measures include rest or minimization of aggravating activities (e.g., running, jumping), heel cups/orthotics, nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and local steroid injection. Improvement may take up to a year in some cases.

Rest/activity modification
Heel cups/orthotics
NSAIDs
Physical therapy
Local steroid injection

Documentation Required

Documentation and Coding Note

No specific documentation requirements are stated in this policy. However, providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable, and retain clinical records supporting medical necessity and prior authorization requests.

Report services with current CPT/HCPCS and ICD-10 codes and appropriate modifiers
Retain clinical documentation that supports medical necessity and any prior authorization

Billing Rule

Coding and Billing Reminder

Providers should report all services using up-to-date procedure, revenue, and diagnosis codes, including modifiers where applicable. Inclusion or exclusion of a code in policy materials does not guarantee coverage; verify member contract benefits at time of service.

Use current industry-standard codes for billing
Verify member-specific coverage prior to billing

Energy levelLow- to medium-energy

Beam characteristicRadial dispersion over a broader surface area versus focal delivery

Regulatory noteRadial (RSW) devices received FDA approval in 2007.

Fracture nonunion — definition and diagnostic criteria

Core definitionFracture nonunion: proposed as failure of progression of fracture healing for at least 3 consecutive months (and at least 6 months after the fracture) accompanied by clinical symptoms of delayed/nonunion (eg, pain, difficulty weight bearing).

Radiographic criteriaSerial radiographs confirm no progressive signs of healing; nonunion radiographs show no evidence of healing.

Clinical considerationsPatient should be adequately immobilized and able to comply with nonweight-bearing limitations; presence of clinical symptoms supports diagnosis.

Additional radiologic thresholdFracture gap of 1 cm or less was used in criteria informing the review.

ESWT — overview and clinical context

DefinitionExtracorporeal shock wave therapy (ESWT): noninvasive therapy using externally applied shock waves for musculoskeletal indications; includes focused and radial modalities and varying protocols.

ModalitiesIncludes focused ESWT (targeted, medium–high energy) and radial ESWT (radial, low–medium energy)

Purported mechanismsMay disrupt calcific deposits, activate endogenous pain control, increase vessel wall permeability, promote angiogenesis and osteogenesis.

Evidence landscapeStudy types include RCTs and systematic reviews with heterogeneous protocols and mixed quality across indications.

NICE guidance references (selected)

NICE IPG311Extracorporeal shockwave therapy for refractory plantar fasciitis: guidance [IPG311] (2009).

NICE IPG376Extracorporeal shockwave therapy for refractory greater trochanteric pain syndrome [IPG376] (2011).

NICE IPG742Extracorporeal shockwave therapy for calcific tendinopathy in the shoulder [IPG742] (Published Nov 2022).

NICE IPG313Reference to NICE guidance on extracorporeal shockwave therapy for tennis elbow (IPG313).