Extracorporeal Shock Wave Lithotripsy (ESWL) for gallbladder and pancreatic stones
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Defines medical necessity criteria and coverage stance for ESWL to treat gallstones, common bile duct stones, and pancreatic duct stones for CareFirst members; applies to providers submitting prior authorization and coverage requests.
CareFirst has adopted the position of MCG Care Guidelines® for medical necessity and clinical appropriateness of ESWL for gallbladder and pancreas.
The policy statement changed from experimental/investigational to medically necessary for ESWL use in treatment of both gallstones and pancreatic stones.
Coverage and Medical Necessity Criteria
Medically necessary criteria for ESWL
ESWL is considered medically necessary when the relevant ALL/AND criteria below are met for the indicated condition.
Applies to all ESWL indications listed
Applies to all ESWL indications listed
Indications
- Common bile duct stones: Common bile duct stone greater than 15 mm in diameter AND failure of endoscopic treatment to remove stone> 15 mm
Also requires patient not pregnant and no coagulopathy (general requirements)
- Gallstones: Normal gallbladder contractility AND patent cystic duct
Also requires patient not pregnant and no coagulopathy (general requirements)
- Surgical contraindication or patient declines: Surgical removal of gallbladder contraindicated or patient declines surgery
Also requires patient not pregnant and no coagulopathy (general requirements)
Pancreatic stones
- Pancreatic stone size/location subcriteria: Either: symptomatic pancreatic duct stone >= 5 mm in diameter that blocks main pancreatic duct OR symptomatic pancreatic duct stone < 5 mm in diameter in main pancreatic duct AND (stone located in body or head of pancreas AND stone unable to be removed by endoscopic sphincterotomy and extraction)>= 5 mm
If <5 mm, both location and endoscopic removal failure must be met
CareFirst has formally adopted the position of MCG Care Guidelines® for clinical appropriateness and medical necessity of Extracorporeal Shock Wave Lithotripsy (ESWL). As a result of this adoption, the policy statement was revised in the 2025 update: the use of ESWL for treatment of both gallstones and pancreatic stones is no longer designated experimental/investigational and is now considered medically necessary when the specified criteria are met.
The policy history documents prior determinations dating back to 2009 through 2021 that consistently maintained ESWL for gallstones as experimental/investigational due to limited peer‑reviewed evidence and the acceptance of laparoscopic cholecystectomy as the standard treatment. Successive literature searches (2009, 2011, 2013, 2015, 2021) found insufficient new data to change that stance until the 2025 review. The 2025 literature review (September 2021–January 2025) led to the adoption of MCG criteria and the change in coverage stance to medically necessary when criteria are met.
Key Clinical Thresholds and Coding-related Values
Prior Authorization, Documentation, and Provider Requirements
Prior authorization contact
Submit prior authorization requests online at www.provider.carefirst.com or by phone at 1-866-773-2884 (1-866-PRE-AUTH) when required by the member's contract or for services/places of service that require authorization.
- Use the online portal for faster processing when available.
- Have the member's contract information available to confirm whether prior authorization is required.
Document prior endoscopic therapy failure
When the criteria require prior endoscopic treatment failure (for example common bile duct stones and certain pancreatic duct stones), document the attempt and failure of endoscopic removal in the prior authorization request and medical record.
- For common bile duct stones: document failure of endoscopic treatment to remove the stone.
- For pancreatic duct stones: document that stone removal by endoscopic sphincterotomy and extraction was attempted and failed when applicable.
Submit request and verify member contract benefits
Providers must submit preauthorization requests online at www.provider.carefirst.com or by phone at 1-866-773-2884 (1-866-PRE-AUTH) and verify the member's contract benefits, since specific contract provisions take precedence over the clinical criteria.
- Confirm whether the member's contract requires prior authorization for the service or place of service.
- Include contract/benefit verification details with the request to avoid processing delays.
Denial risk if authorization not obtained
Failure to obtain required prior authorization where applicable may result in denial of coverage; always check and obtain authorization when the member's contract specifies it.
- Denials can occur if authorization is not obtained for services/places of service that require it under the member's contract.
- Obtain and document prior authorization before performing ESWL when contract requires it.
Clinical Background
Pancreatic stones are calcified deposits that typically form in the setting of chronic pancreatitis and can obstruct the main pancreatic duct. Extracorporeal Shock Wave Lithotripsy (ESWL) is a noninvasive treatment that uses focused high‑intensity shock waves to fragment stones so they can be removed endoscopically or pass spontaneously. Typical treatment parameters reported include approximately 500–1500 shocks delivered over a procedure lasting about 30–120 minutes, and ESWL is most often performed with general, spinal, or adequate analgesic/anesthetic support.
Definitions
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