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BCBSRI medical coverage policy addressing use of extracorporeal shock wave therapy (focused/high-energy, low-energy, and radial ESWT) for plantar fasciitis and a range of musculoskeletal and neurologic conditions; defines coverage stance, coding guidance, and clinical background. Applies to Commercial Products and BlueCHiP for Medicare as indicated.
No material clinical or coverage changes identified in this update.
BCBSRI medical coverage policy on Extracorporeal Shock Wave Therapy (ESWT) addresses focused/high-energy, low-energy, and radial ESWT for plantar fasciitis and a range of musculoskeletal and neurologic conditions. Background: ESWT is a noninvasive treatment delivering shock or sound waves to target tissues, available as focused (high- to medium-energy) and radial (low- to medium-energy) forms. Coverage stance: Not covered / Not medically necessary — ESWT (high-dose, low-dose, or radial) is not covered as a treatment of musculoskeletal conditions because evidence is insufficient to determine effects on health outcomes.
Policy Statement - Coverage Determination
Extracorporeal shock wave therapy is
Rationale: evidence is insufficient to determine effect on health outcomes
Commercial Products Specific Statement
For Commercial Products
Evidence insufficient
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy |
| 0102T | Extracorporeal shock wave; high energy, performed by a physician, requiring anesthesia other than local, involving 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. |
| 20999 | Unlisted musculoskeletal procedure (to be used for low-energy or radial ESWT as there is no specific CPT code) |
Document lack of healing for fracture nonunion/delayed union
Document that the fracture has not healed or is showing a decelerating healing process and that the fracture is amenable to immobilization and patient compliance. Maintain serial radiographs showing no progressive signs of healing (or decelerating healing with lack of clinical/radiologic union for ≥3 months), documentation that the fracture can be adequately immobilized and the patient is likely to comply with non‑weight bearing, and measurement of the fracture gap (≤1 cm for nonunion).
Extracorporeal shock wave therapy (ESWT) includes focused and radial modalities; focused ESWT delivers medium- to high-energy shockwaves directed at a target often with imaging guidance, while radial ESWT transmits low- to medium-energy shockwaves radially over a surface area. The FDA has granted premarket approvals for multiple focused ESWT devices (examples: Epos Ultra, OssaTron, SONOCUR, Orbasone, Orthospec, Duolith SD1) with labeled indications mainly for chronic proximal plantar fasciitis and some approvals specific to lateral epicondylitis. Both high-dose and low-dose treatment protocols have been investigated. Overall, the policy concludes that the evidence is insufficient to determine the effects of ESWT on health outcomes for many musculoskeletal and neurologic indications.
| Evidence type | Details |
|---|---|
| FDA premarket approvals | |
| Multiple focused ESWT devices approved: Epos Ultra (2002); OssaTron (2000); SONOCUR Basic (2002); Orbasone Pain Relief System (2005); Orthospec Orthopedic ESWT (2005); Duolith SD1 (2016) — indications mainly for chronic proximal plantar fasciitis and some lateral epicondylitis. | |
| Systematic reviews / RCT meta-analyses referenced | |
| Multiple meta-analyses and randomized controlled trials cited (examples: Sun J 2017; Wang Lou 2017; Gollwitzer 2015; Gerdesmeyer et al.; various RCTs and Cochrane/systematic reviews) but policy concludes evidence insufficient for broad coverage. |
High-dose protocol: Single treatment of high-energy shock waves (example described as ~1300 mJ/mm2), typically requiring anesthesia and performed in a hospital or ambulatory surgery center.
Low-dose protocol: Multiple lower-dose treatments spaced one week to one month apart, usually performed in the office without anesthesia.
Radial ESWT (RSW): Ballistically generated radial shock waves with lower- to medium-energy transmitted radially over a surface area, often used for superficial tendinopathies.
| Name | Type / Number / Effective date |
|---|---|
| BlueCHiP for Medicare National and Local Coverage Determinations New Technology |
Policy effective date as listed in document header.
Policy last updated date as listed in document header; policy status CURRENT.
Evidence Insufficiency List
The evidence is insufficient to determine effects of ESWT on health outcomes for individuals who have any of the following:
ANY of the following
Fracture Nonunion / Delayed Union Definitions
Criteria used to define fracture nonunion/delayed union in background section:
ALL of the following
Delayed union
Use of unlisted CPT for low-energy/radial ESWT
Report low‑energy or radial ESWT using the unlisted musculoskeletal procedure code because there is no specific CPT for low‑energy or radial ESWT. Use CPT 20999 (unlisted musculoskeletal procedure) when billing low‑energy or radial ESWT.
Do not bill covered/procedure codes
Do not bill the listed high‑energy/covered procedure codes for ESWT; CPT codes 0101T and 0102T (and CPT 28890) are identified in the policy as not covered / not medically necessary for BlueCHiP for Medicare and Commercial Products and claims using these codes may be denied.