CurrentCapital BluecrossPolicy MP 2.034

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Defines Capital Blue Cross coverage position on extracorporeal shock wave therapy (ESWT), including focused and radial ESWT, for plantar fasciitis and a range of musculoskeletal and neurologic conditions; states investigational status and summarizes evidence, FDA device approvals, and coding guidance. Applies to certain programs/products administered by Capital Blue Cross with benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyExtracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Policy CodePolicy MP 2.034

Change TypeAdministrative update (coding/reference updates; no clinical change)

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders should note that ESWT is considered investigational for musculoskeletal conditions per this policy; coverage determination is subject to member benefit plan terms and eligibility.

POLICY UPDATE CHANGES

New code 0864T added effective 01/01/2024; clinical benefit language added 01/19/2024; references and formatting updated on multiple consensus reviews with no change to coverage stance.

1Policy stance (investigational)

5FDA-cleared devices listed

9Key references cited (sample)

MultipleEvidence citations

Coverage Summary

Defines Capital Blue Cross coverage position on extracorporeal shock wave therapy (ESWT), including focused and radial ESWT, for plantar fasciitis and a range of musculoskeletal and neurologic conditions; ESWT is considered investigational for musculoskeletal conditions and the evidence is insufficient to support a general conclusion concerning health outcomes or benefits.

Coverage stance: Investigational / Cosmetic — not covered for musculoskeletal conditions (Policy number: MP 2.034; Effective date: 1/1/2026).

Quick note: Summaries of FDA device indications are provided in the policy for informational purposes only and do not alter the investigational coverage stance.

Medical Necessity / Investigational Determinations

Medically Necessary / Investigational Determination

Policy statement:

ALL of the following

Extracorporeal shock wave therapy (ESWT) using either a high- or low-dose protocol or radial ESWT is considered investigational as a treatment of musculoskeletal conditions, including but not limited to plantar fasciitis; tendinopathies (shoulder, lateral epicondylitis, Achilles, patellar); stress fractures; avascular necrosis of the femoral head; delayed union and non-union of fractures; and spasticity.
There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Device-specific FDA Indications (informational only)

FDA-approved device indications summarized in policy (does not alter investigational stance):

Examples of FDA device indications

OssaTron® (HealthTronics) — Indication: Chronic proximal plantar fasciitis (pain >6 months unresponsive to conservative management) and lateral epicondylitis.
Sonocur® Basic (Siemens) — Indication: Plantar fasciitis and chronic lateral epicondylitis (unresponsive to conservative therapy for >6 months).
Orthospec™ (Medispec) — Indication: Chronic proximal plantar fasciitis in patients ≥18 years.
Orbasone™ Pain Relief System (Orthometrix) — Indication: Chronic proximal plantar fasciitis in patients ≥18 years.
Duolith® SD1 (Storz Medical AG) — Indication: Plantar fasciitis in patients ≥18 years with history of failed alternative conservative therapies >6 months.

Coding

Investigational / therefore not covered procedure codesCPTNot Covered

0101T	Extracorporeal shock wave therapy (ESWT) procedure code
0102T	Extracorporeal shock wave therapy (ESWT) procedure code
0864T	Extracorporeal shock wave therapy — new administrative code added effective 01/01/2024
20999	Unlisted procedure, generic; referenced in coding list as applicable to ESWT*
28890	Extracorporeal shock wave treatment procedure code

Added administrative codeCPT

0864T

New code added effective 01/01/2024 (administrative update)

Provider Actions

Documentation Required

Document investigational status

Providers should document that extracorporeal shock wave therapy (ESWT) is considered investigational for musculoskeletal conditions per this policy; coverage determination remains subject to the member's benefit plan terms and eligibility.

0101T
0102T
0864T
20999
28890

Billing Rule

Codes may not denote coverage

Identification of procedure or billing codes in the coding section does not denote coverage; claims will be adjudicated according to the member's benefit information and medical necessity determinations.

Background & Evidence Summary

Extracorporeal shock wave therapy (ESWT) — also called orthotripsy — uses externally applied shock waves that create transient pressure disturbances; proposed mechanisms for musculoskeletal effects include disruption of calcific deposits, stimulation of angiogenesis and osteogenesis, and modulation/reset of endogenous pain pathways via physical stimulation and microtrauma promoting healing.

There are two general forms: focused ESWT (medium- to high-energy, single pressure pulses directed to a specific target, often using ultrasound or radiographic guidance) and radial ESWT (low- to medium-energy shockwaves transmitted radially over a larger surface area to address larger or more superficial treatment regions).

Both high-energy and low-energy protocols have been investigated: a high-dose protocol typically is a single, painful treatment (example energy cited: 1300 mJ/mm2) that usually requires anesthesia; a low-dose protocol consists of multiple lower-dose treatments spaced 1 week to 1 month apart and does not require anesthesia.

Selected ESWT devices have received FDA approval/clearance for specific indications (e.g., chronic proximal plantar fasciitis, lateral epicondylitis); these FDA device indications are summarized elsewhere in the policy and are informational only — they do not change the policy’s investigational stance.

Fasciotomy — a surgical incision into an area of fascia (connective tissue).

Revision History

03/24/2020consensus_review

Consensus review — references updated; no changes to policy statement.

10/25/2021consensus_review

Consensus review — updated cross-reference, FEP, regulatory status, and references; no changes to coding.

07/25/2022consensus_review

Consensus review — formatting update to tables, coding and literature review; updated references.