CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Policy governs medical coverage determination for extracorporeal shock wave therapy (ESWT), including focused and radial devices and high- and low-dose protocols, for plantar fasciitis and other musculoskeletal and neurologic conditions for commercial and Medicare Advantage products offered by BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Policy CodePolicy N/A

Change Typeclarified

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionWhen no specific CPT code exists for low-energy or radial ESWT, report the unlisted musculoskeletal procedure code 20999 and verify member benefits prior to billing.

SourceLink

POLICY UPDATE CHANGES

Policy states ESWT (high-, low-dose, or radial) is not covered as treatment for musculoskeletal conditions due to insufficient evidence.

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Coverage Summary

Policy scope: Coverage determination for Extracorporeal Shock Wave Therapy (ESWT) — including focused and radial devices and both high- and low-dose protocols — for plantar fasciitis and other musculoskeletal and neurologic conditions for Commercial and Medicare Advantage products. Effective date: 2015-10-01; status: CURRENT (last reviewed 2025-08-20).

Coverage stance: ESWT is not covered (not medically necessary) for musculoskeletal conditions. Rationale: the evidence is considered insufficient to demonstrate an improvement in net health outcome across the listed indications.

Policy Effective2015-10-01

Last Review2025-08-20

Next Review

Coverage StanceNot covered / Not medically necessary

Example listed conditions not covered9

Example CPT/Procedure Codes Mentioned3

Time since fracture for delayed union/nonunion>= 3 months

Fracture gap<= 1 cm

Medical Necessity / Not Medically Necessary Criteria

Coding

Not Covered / Not Medically Necessary CPTCPTNot Covered

0101T	Extracorporeal shock wave-involving musculoskeletal system, not otherwise specified
0102T	Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia (Medicare Advantage listed)

Unlisted / Use When No Specific Code ExistsCPT

20999

Unlisted procedure, musculoskeletal system (use for low-energy or radial ESWT when no specific CPT exists)

Provider Actions & Billing Guidance

Billing Rule

Use of CPT 20999 for low-energy/radial ESWT

Report CPT 20999 (unlisted musculoskeletal procedure) when no specific CPT exists for low-energy or radial ESWT.

20999

Billing Rule

Codes Not Covered for Medicare Advantage and Commercial

CPT codes 0101T and 0102T are identified as not covered/not medically necessary for Medicare Advantage Plans and Commercial Products; CPT 28890 is listed for Medicare Advantage but policy indicates it is not covered.

0101T
0102T
28890

Background and Evidence Summary

Background: ESWT is a noninvasive therapy that delivers shock or sound waves (focused or radial) from outside the body to a target area. Two general device types are described: focused ESWT (directed medium- to high-energy pulses to a specific target, often with imaging guidance) and radial ESWT (rESWT) which transmits low- to medium-energy shockwaves radially over a surface area.

Regulatory approvals: The FDA first approved focused ESWT devices for orthopedic use starting in 2000–2002 and approved radial ESWT devices later (first PMA radial device in 2007). The brief lists 6 focused ESWT devices approved via FDA PMA for orthopedic indications (examples and dates provided in the source). Specific PMA-labeled indications include chronic proximal plantar fasciitis and, for some devices, lateral epicondylitis.

Mechanism and dose uncertainty: The mechanism by which ESWT might affect musculoskeletal conditions is not well-defined; proposed mechanisms include disruption of calcific deposits, microtrauma promoting angiogenesis, endothelial changes increasing cytokine diffusion, and stimulation of osteogenesis, but these are uncertain.

Overall evidence conclusion: Across multiple musculoskeletal and neurologic indications (including plantar fasciitis, lateral epicondylitis, shoulder and Achilles tendinopathies, medial tibial stress syndrome, patellar tendinopathy, osteonecrosis of the femoral head, nonunion/delayed union, and spasticity), the evidence is judged insufficient to demonstrate an improved net health outcome.

FDA PMA approved focused ESWT devices6 devices approved for orthopedic use (2000-2016) with indications including plantar fasciitis and lateral epicondylitis

Medicare / Medicare Advantage Determinations

Medicare and billing determinations: A Medicare Advantage Plans statement is included in the policy. The policy specifies that the following CPT codes are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products: 0101T and 0102T.

Additionally, CPT 28890 (extracorporeal shock wave, high energy involving the plantar fascia, requiring anesthesia) is listed for Medicare Advantage but the policy indicates it is not covered. For low-energy or radial ESWT when no specific CPT exists, report the unlisted musculoskeletal procedure code 20999.

The policy changes clarify that the not-covered stance for ESWT (high-, low-dose, or radial) applies to both Commercial products and Medicare Advantage per the policy.

Revision History

2025-08-20policy_revisionLatest

Applies to commercial products and Medicare Advantage statements; policy states ESWT (high- or low-dose protocol or radial ESWT) is not covered as a treatment of musculoskeletal conditions because evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

2015-10-01policy_effective

Policy effective date established for Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions; covers focused and radial ESWT and notes FDA approvals for certain devices but indicates insufficient evidence across multiple musculoskeletal indications.