Loading...
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 states ESWT (high-, low-dose, or radial) is not covered as treatment for musculoskeletal conditions due to insufficient evidence.
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.
| 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) |
| 20999 | Unlisted procedure, musculoskeletal system (use for low-energy or radial ESWT when no specific CPT exists) |
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.
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.
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.
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.
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.
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.
Benefit Verification
Verify member-specific benefits and eligibility prior to providing ESWT.
Definitions:
• High-dose protocol: A single treatment of high-energy shock waves (example cited ~1300 mJ/mm2) that typically requires anesthesia.
• Low-dose protocol: Multiple treatments given one week to one month apart at lower energy; this protocol typically does not require anesthesia.
• Radial ESWT (rESWT): Low- to medium-energy shockwaves transmitted radially over a surface area and generated ballistically; described as an alternative to focused ESWT and often used for more superficial or larger-area applications.
Clarification: Applies to commercial products and Medicare Advantage statements; no clinical policy statement changes noted in revision history (non-material change).