CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

This policy governs coverage and medical necessity determinations for extracorporeal shock wave therapy (focused and radial, high- and low-energy protocols) for plantar fasciitis and other musculoskeletal and neurologic conditions for Blue Cross Blue Shield - Rhode Island members.

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 changes

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionVerify member benefits and eligibility with the provider call center before providing extracorporeal shock wave therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

not coveredESWT for musculoskeletal conditions

6FDA-approved focused ESWT devices

>=18Minimum patient age (some devices)

1300Example high-dose energy

2019-05-11

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Coverage Determinations

Not covered / Not medically necessary

Covered when ALL of the following are met:

General coverage stance: Extracorporeal shock wave therapy (high- or low-dose protocols or radial ESWT) is considered not covered/not medically necessary for musculoskeletal conditions including but not limited to plantar fasciitis, lateral epicondylitis, shoulder tendinopathy, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, osteonecrosis of the femoral head, fracture nonunion/delayed union, and spasticity because the evidence is insufficient to determine effects on health outcomes.

For Commercial Products, this policy applies to high- and low-dose focused ESWT and radial ESWT; FDA approval for select devices is limited to chronic proximal plantar fasciitis in adults with prior unsuccessful conservative therapy, but that indication does not change the policy stance that ESWT is considered not medically necessary for the listed musculoskeletal conditions.

Extracorporeal shock wave therapy (ESWT) — including high- and low-dose protocols and radial ESWT — is not covered / not medically necessary for musculoskeletal conditions. Examples include, but are not limited to, plantar fasciitis, lateral epicondylitis (tennis elbow), shoulder tendinopathy, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, osteonecrosis of the femoral head, fracture delayed union/nonunion, and spasticity. The policy rationale is that the evidence is insufficient to determine the effects of ESWT on health outcomes for these indications.

Benefits and eligibility are determined by the member's subscriber agreement or employer agreement, which supersede this medical policy. If a service is determined to be a non-covered benefit or not medically necessary under those agreements, providers may not bill the member unless the member has been informed in writing and has agreed in advance to self-pay; providers should refer to their participation agreements and contact the provider call center for member-specific information.

For Commercial Products, extracorporeal shock wave therapy (whether high- or low-dose protocols or radial ESWT) is considered not medically necessary for the listed musculoskeletal conditions because available evidence does not demonstrate improved health outcomes.

Services determined to be not medically necessary or that are non-covered benefits may be denied and are not covered under the member's plan. Providers may not bill members for such services unless the member was notified in writing and provided advance written agreement to accept financial responsibility.

Coding and Code Examples

Covered/Listed CPT CodesCPT

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.

Not covered / not medically necessary CPT CodesCPTNot 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

Unlisted CPTCPT

20999

Unlisted CPT code for musculoskeletal procedure (to be used for low-energy or radial ESWT)

High-dose energy example

Example high-dose energy level1300 mJ/mm2 (single high-energy treatment)

High-dose protocol settingSingle treatment of high-energy shock waves typically performed in hospital or ambulatory surgery center and may require anesthesia

FDA-labeled devices with high-dose protocolsOssaTron and EposTM Ultra labeled indications specifically describe a high-dose protocol

Provider Responsibilities and Billing Guidance

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization: Not applicable. Benefits and coverage can vary by contract; verify member-specific benefits and prior authorization requirements before scheduling ESWT.

Verify eligibility and benefits with the payer or vendor prior to service
Obtain prior authorization when required by the member's contract

Denial Risk

Denial Risk for Non‑Covered or Not Medically Necessary Services

Claims for extracorporeal shock wave therapy (ESWT) for musculoskeletal conditions may be denied as not medically necessary because the evidence is insufficient to determine clinical benefit for these indications.

Denial risk applies to indications including plantar fasciitis, tendinopathies, lateral epicondylitis, Achilles tendinitis, patellar tendinitis, spasticity, stress fractures, delayed/nonunion fractures, and avascular necrosis of the femoral head

Background and Scope

Extracorporeal shock wave therapy (ESWT) is a noninvasive treatment that delivers shock waves to musculoskeletal tissues. Focused ESWT concentrates medium- to high-energy waves on a targeted area (often with ultrasound or radiographic guidance) and may be used for deeper or calcific lesions; some focused devices have FDA approvals. Radial ESWT is generated ballistically and transmits lower- to medium-energy waves radially across a surface area, making it suitable for more superficial applications such as tendinopathies. Proposed mechanisms include disruption of calcific deposits, stimulation of angiogenesis and osteogenesis, and modulation of endogenous repair processes. Protocols vary from single high-energy treatments (which may require anesthesia) to multiple low-energy office treatments without anesthesia.

Device and Treatment Definitions

Focused ESWT — device/energy description and FDA approvals

Definition / deliveryFocused ESWT sends medium- to high‑energy shockwaves concentrated on a target, often with ultrasound or radiographic guidance

FDA approvals (focused devices)Six focused ESWT devices have FDA premarket approvals for orthopedic use (Epos Ultra, OssaTron, SONOCUR Basic, Orbasone Pain Relief System, Orthospec, Duolith SD1)

FDA-indicated patient age for some devices>=18 years for several devices (Orbasone, Orthospec, Duolith SD1 labeled for chronic proximal plantar fasciitis in patients ≥18)

Protocol typesBoth high-dose (single high-energy treatment, may require anesthesia) and low-dose (multiple lower-energy office treatments without anesthesia) protocols have been investigated; some device labels specify which protocol

Radial ESWT (RSW) — device/energy description and typical uses