CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

This policy defines Blue Cross Blue Shield - Rhode Island's coverage stance on extracorporeal shock wave therapy (ESWT) for plantar fasciitis and various musculoskeletal and neurologic conditions and applies to Commercial and Medicare Advantage products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyExtracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review Date

Key ActionVerify member benefits and prior authorization requirements via the BCBSRI provider call center before delivering ESWT services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCoverage stance (Commercial)

Not coveredCoverage stance (general)

28890, 0101T, 0102TKey CPT codes

FDA approvals citedFDA-approved devices

Multiple

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Conditions referenced

Coverage Determinations for ESWT

Not medically necessary / Not covered

Covered when ALL of the following are met:

General coverage decision: Extracorporeal shock wave therapy (focused or radial; high- or low-dose protocols) is not covered / considered not medically necessary for treatment of musculoskeletal conditions because evidence is insufficient to demonstrate improved net health outcome

applies to Commercial Products and broadly stated in policy

Conditions with insufficient evidence: plantar fasciitis; lateral epicondylitis; shoulder tendinopathy; Achilles tendinopathy; patellar tendinopathy; medial tibial stress syndrome; osteonecrosis of the femoral head; nonunion or delayed union of fractures; spasticity

list as provided in policy

Extracorporeal shock wave therapy (ESWT), including focused or radial techniques and high- or low-dose protocols, is not covered as a treatment for musculoskeletal conditions. Conditions specifically listed in the policy include, but are not limited to, plantar fasciitis, various tendinopathies (for example shoulder, elbow/lateral epicondylitis, Achilles, and patellar tendinitis), spasticity, stress fractures, delayed union and nonunion of fractures, and avascular necrosis of the femoral head; the policy states evidence is insufficient to demonstrate an improvement in net health outcome.

For Commercial Products, ESWT — whether delivered by a high- or low-dose protocol or as radial ESWT — is considered not medically necessary for musculoskeletal conditions, and specific CPT codes (for example 0101T and 0102T) are listed as not medically necessary or not covered in the coding section.

Member benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement, and those documents will supersede the provisions of this medical policy. Providers should confirm member-specific coverage before delivering services.

CPT / HCPCS Codes and Coverage Status

Covered CPT Codes (referenced)CPT

28890

Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance; involving the plantar fascia

Not covered / Not medically necessary CPT codesCPTNot Covered

0101T	Extracorporeal shock wave therapy; involving musculoskeletal system, not otherwise specified (Revised text 1/01/2022)
0102T	Extracorporeal shock wave performed by physician, requiring anesthesia other than local, involving lateral humeral epicondyle (Revised text 1/01/2022) therapy

Billing, Authorization, and Provider Responsibilities

Prior Authorization

Prior authorization is not required for extracorporeal shock wave therapy (ESWT).

Denial Risk

Denial Risk and Member Liability

Claims for ESWT may be denied as not covered or not medically necessary under this policy. Verify member benefits and coverage terms prior to billing.

ESWT services may be denied as not covered or not medically necessary per policy
Do not bill members for services determined to be not medically necessary or non-covered unless the member has been informed and provided written agreement in advance

Note

Clinical Context

Plantar fasciitis is a common cause of heel pain characterized by tenderness at the medial calcaneal tubercle; most cases are managed with conservative measures such as rest or activity modification, heel supports or orthotics, nonsteroidal anti-inflammatory drugs, steroid injections, and physical therapy. ESWT is a noninvasive external modality that has received FDA approvals for some devices in chronic proximal plantar fasciitis, but this policy concludes that ESWT is not covered or is not medically necessary for musculoskeletal conditions because the evidence is insufficient to demonstrate improved net health outcomes.

Definitions of ESWT Types

inv-16: Focused ESWT — definition, energy profile, and FDA approvals where applicable

DefinitionFocused ESWT delivers medium- to high-energy shockwaves as single pressure pulses directed at a specific target, sometimes using ultrasound or radiographic guidance.

Energy profileMedium- to high-energy pulses delivered as focused single pressure waves (microseconds duration).

FDA approvalsFDA first approved focused ESWT devices for orthopedic use in 2002; currently six focused ESWT devices have received FDA premarket approval for orthopedic indications.

Typical clinical rationaleProposed mechanisms include microtrauma-induced angiogenesis, stimulation of osteogenesis, and modulation of endogenous pain/healing pathways, though mechanisms for musculoskeletal benefit are not well-defined.

inv-17: Radial ESWT (RSW) — definition, energy profile, and typical indications

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyExtracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review Date

Key ActionVerify member benefits and prior authorization requirements via the BCBSRI provider call center before delivering ESWT services.

SourceLink

On This Page

Verify Benefits and Prior Authorization

Benefits and coverage vary by contract. Providers should verify member benefits, eligibility, and any prior authorization requirements with Blue Cross Blue Shield of Rhode Island before delivering ESWT services.

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits
Contact the BCBSRI provider call center for member-specific benefit information

Documentation Required

Conservative Therapy Context

Conservative therapies (e.g., rest, activity modification, physical therapy, NSAIDs, heel supports, local steroid injection for plantar fasciitis) are usual treatment prior to considering ESWT.

Document prior conservative therapy attempts and outcomes when considering ESWT

Note

Benefit Verification Requirement

Check subscriber and employer agreements for member-specific benefits and eligibility. This policy is informational and does not guarantee payment; the subscriber agreement governs coverage.

Policy statements may be revised; always confirm current coverage rules
Follow participation agreements for applicable billing and member notification requirements

Radial ESWT (RSW) generates shockwaves that transmit low- to medium-energy pulses radially over a larger surface area; production is often ballistic (accelerating a projectile to strike an applicator).

Energy profileLow- to medium-energy radial pressure waves distributed over a broader treatment area rather than a focused single-point pulse.

FDA-approved indicationIn 2007, the Dolorclast (EMS Electro Medical Systems) radial ESWT device received FDA premarket approval for treatment of adults (≥18 years) with chronic proximal plantar fasciitis after unsuccessful conservative therapy.

Typical use casesDescribed as more suitable for superficial tendinopathies and larger treatment areas compared with focused ESWT, but evidence is insufficient for multiple musculoskeletal indications.