Verify benefit plan, laws/regulations, and collateral materials

Coverage determinations require review of the member's applicable benefit plan document, relevant laws/regulations, collateral materials (including Cigna Coverage Policies and delegated vendor guidelines where applicable), and the specific facts of the case before a coverage decision is made.

Prior authorization must document failed conservative therapy (typically ≥3 months)

Obtain prior authorization when required and include documentation confirming failure of conservative therapy—studies and policy references generally require at least 3 months of conservative care prior to advanced biologic or procedural treatments.

• Submit clinical documentation showing prior conservative therapy attempts and durations (typically ≥3 months as required in PRP trials).
• Include trial or outcomes data when available to support medical necessity determinations.

Prior-authorize ESWT per FDA PMA indication and document symptom duration

For requests for ESWT, prior authorization should confirm the device is being used consistent with FDA PMA indications: chronic proximal plantar fasciitis in adults with symptoms ≥6 months that have failed conservative therapy.

• Document symptom duration (≥6 months) and prior conservative therapy attempts and objective outcome measures referenced in trials (e.g., VAS, AOFAS).
• Note device regulatory status (ESWT devices = FDA Class III, PMA).

Prior authorization required for experimental/unproven procedures with supporting evidence

Treatments described in the policy as experimental, investigational, or unproven (for example, coblation, IPST, percutaneous ultrasonic ablation, stereotactic radiofrequency thermal lesioning, and stem cell therapies) generally require prior authorization and submission of supporting evidence; absence of high-quality supportive evidence may result in denial.

• Provide randomized trial data or technology-assessment evidence when available; if not provided, requests may be denied as unproven.
• Policy revisions on 5/15/2026 affirm prior authorization and evidence requirements for these modalities.

Require documented progression through first‑ and second‑line conservative care

Follow stepwise conservative therapy: initial first‑line care (stretching, ice, activity modification, weight management, appropriate footwear, arch taping, NSAIDs, shock‑absorbing inserts/orthoses) and progress to second‑line measures (night splints, steroid injections, short‑leg walking cast) before considering advanced interventions.

• Surgery considered only after 6–12 months of proper conservative treatment.
• Document each conservative modality tried and duration as part of the authorization request.

Document prior conservative therapy before biologic or procedural treatments

Document stepwise management with recorded conservative measures (e.g., RICE, stretching, NSAIDs, orthotics) prior to biologic injections or procedural therapies; many studies and trial inclusion criteria required prior conservative treatment.

• Include dates, modalities, and patient response for each conservative intervention.
• Note exclusions: prior surgery, trauma, or other confounding conditions may affect eligibility per trial criteria.

Conservative-care failure is a prerequisite in many trials—document before advanced therapy

Recognize that many clinical studies require failure of conservative care (stretching, NSAIDs, heel pads, orthotics, exercise) prior to enrollment; consider this conservative therapy prerequisite when evaluating coverage and prior authorization requests.

• Ensure prior conservative therapy duration and content match study or device indication requirements when used to support coverage.

Document prior conservative therapies (stretching, orthoses, night splints, injections)

When requesting coverage, include explicit documentation of prior conservative therapies such as stretching programs, use of orthoses or night splints, and any prior injections (steroid or other), with dates and clinical response.

• List each conservative measure tried, the start and end dates, patient adherence, and objective or subjective response.
• Attach relevant clinical notes, imaging, and trial outcome measures when available.

Use correct, policy‑effective procedure codes or risk denial

Use the most appropriate CPT/HCPCS codes effective on the date of service; claims for services lacking covered codes under this policy will be denied as not covered.

• Avoid billing codes explicitly listed as Not Medically Necessary (e.g., 28899) for plantar fasciitis treatments.
• Confirm applicable code groups in the policy Coding section before claim submission.

Provide required clinical documentation: prior conservative failure and objective outcome measures

Include clinical documentation showing duration of failed conservative therapy (studies generally required ≥3 months), and objective pain/function measures (e.g., VAS, AOFAS, FFI) when requesting coverage for biologics or procedures.

• For PRP and other biologics, include details of biologic preparation/administration given variability in methods.
• Attach outcome measures reported in trials to support medical necessity.

ESWT-specific documentation: prior therapy duration (≥6 months) and objective outcomes

For ESWT requests, document prior conservative therapy attempts and duration consistent with the FDA indication (e.g., symptoms ≥6 months) and include objective outcome measures and trial data when available.

• Include VAS, AOFAS, FADI, or plantar fascia thickness measurements used in supporting trials.
• Attach relevant randomized trial or technology-assessment evidence if requesting coverage despite mixed evidence.

Attach clinical notes, imaging, and trial evidence for minimally invasive procedures or ESWT

Include supporting clinical documentation—clinical notes, imaging, and trial data—when requesting coverage for minimally invasive procedures or ESWT because the literature notes limited study quality and the need for rigorous supporting evidence.

• Provide randomized controlled trial data or technology assessment citations when available to substantiate medical necessity.
• Attach imaging (e.g., ultrasound of plantar fascia) and pre/post outcome measures.

Claims lacking covered codes will be denied

Claims submitted without a covered code under this policy will be denied as not covered; verify coding aligns with the policy Coding Information prior to submission.

• Denials may result if the service is billed with codes that are not listed as covered for the procedure.

Use of Not Medically Necessary codes (e.g., 28899) may trigger denial

Avoid billing codes listed as Not Medically Necessary for plantar fasciitis (for example, unlisted foot procedure 28899 and listed bone marrow/hematopoietic progenitor cell harvesting codes), as their use may trigger claim denial.

• Confirm whether a code appears in the policy's Not Medically Necessary code list before billing.

Insufficient/highly heterogeneous evidence for biologics may lead to denial

Be aware that interventions with insufficient high‑quality evidence—such as amniotic‑derived allografts and PRP when unsupported by trial criteria—may be denied if submitted without meeting policy criteria or without high‑quality supportive evidence.

• For amniotic-derived allografts, the policy states there is insufficient evidence to support use for plantar fasciitis.
• For PRP, heterogeneity and mixed results mean coverage is limited unless trial-aligned documentation is provided.

Autologous whole blood injections lack evidence and may be denied

Autologous whole blood injections are not recommended based on review evidence; submission for coverage without supportive high-quality evidence may be denied as not medically necessary.

• The systematic review found strong evidence that autologous whole blood injections should not be recommended for chronic tendinopathy/plantar fasciitis.

Unproven procedures are likely to be denied without high‑quality evidence

Procedures classified as unproven in the policy (e.g., coblation, intracorporeal pneumatic shock therapy, percutaneous ultrasonic ablation, stem cell therapies, stereotactic radiofrequency lesioning) are likely to be denied unless high‑quality supportive evidence is submitted.

• Provide rigorous RCTs or technology-assessment findings to overcome unproven status; absent such evidence, expect denial.

ESWT may be denied without indication‑consistent documentation and supportive evidence

Recognize ESWT carries uncertainty in efficacy and cost‑effectiveness per technology assessments (e.g., WSHCA); requests for ESWT may be denied when supportive, high‑quality evidence or indication‑consistent documentation is lacking.

• When requesting ESWT coverage, include trial evidence and documentation that the indication and symptom duration (≥6 months) meet FDA-labeled criteria.