CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

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.

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 TypeNo material change

Effective DateOct 1, 2015

Next Review Date

Key ActionMaintain and document serial radiographs and fracture healing criteria for nonunion/delayed union, document immobilization feasibility and patient compliance, and use CPT 20999 for low-energy or radial ESWT while avoiding billing codes 0101T, 0102T, and 28890 which are listed as not covered/not medically necessary.

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POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this update.

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Coverage Summary

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.

Surface thresholds and quick facts

Fracture duration threshold>= 3 months

Fracture gap threshold<= 1 cm

Conditions listed as having insufficient evidence9 (see evidence insufficiency list)

FDA‑approved focused ESWT devices listed3 (policy lists multiple devices; three examples: Epos Ultra, OssaTron, SONOCUR)

Context noteThresholds used to define nonunion/delayed union in policy background

Medical Necessity / Coverage Determinations

Policy Statement - Coverage Determination

Extracorporeal shock wave therapy is

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

Rationale: evidence is insufficient to determine effect on health outcomes

Commercial Products Specific Statement

For Commercial Products

Extracorporeal shock wave therapy (either high- or low-dose protocol or radial ESWT) is considered not medically necessary for musculoskeletal conditions including but not limited to chronic proximal plantar fasciitis; shoulder tendinopathy; lateral epicondylitis; Achilles tendinopathy; patellar tendinopathy; spasticity; stress fractures; delayed union and nonunion of fractures; and avascular necrosis of the femoral head

Evidence insufficient

Coding Guidance

Not covered / Not medically necessary CPT codes (BlueCHiP for Medicare and Commercial)CPTNot Covered

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

CPT code for high-energy plantar fascia procedure (reference)CPTNot Covered

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.

Unlisted code guidance for low-energy or radial ESWTCPT

20999

Unlisted musculoskeletal procedure (to be used for low-energy or radial ESWT as there is no specific CPT code)

Provider Actions & Billing Rules

Documentation Required

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).

Serial radiographs documenting no progressive signs of healing or decelerating healing over time
Documentation of immobilization feasibility (fracture can be adequately immobilized)
Documentation of patient ability/willingness to comply with non‑weight bearing restrictions
Measured fracture gap (≤ 1 cm for nonunion)

Background, Evidence, and Definitions

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.

Medicare Determinations

Name	Type / Number / Effective date
BlueCHiP for Medicare National and Local Coverage Determinations New Technology

Revision History

2015-10-01Effective Date

Policy effective date as listed in document header.

2019-11-05Last ReviewLatest

Policy last updated date as listed in document header; policy status CURRENT.