Plantar Fasciitis Treatments
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Defines Cigna's coverage stance for various minimally invasive, injectable, device-based, and other non-surgical treatments for plantar fasciitis for members covered by Cigna-administered health benefit plans.
Revised policy statement for not medically necessary treatments for plantar fasciitis.
Revised policy statement for experimental, investigational or unproven treatments for plantar fasciitis.
Coverage Criteria for Plantar Fasciitis Treatments
Coverage determinations for listed nonstandard therapies
Coverage stance for specified therapies:
listed explicitly in policy
listed explicitly in policy
Standard conservative and surgical pathway
Standard of care and sequencing before advanced or surgical interventions:
prefabricated orthoses adequate for majority
steroid injections provide short-term benefit; risks include plantar fascia rupture and fat pad atrophy
endoscopic plantar fasciotomy appears effective based on nonrandomized studies
Autologous platelet-rich plasma (PRP)
Summary of evidence-based stance derived from literature in this section
Supported by systematic reviews/meta-analyses (Zuo 2025; Yang 2017) and multiple RCTs reporting variable outcomes.
Amniotic-derived allografts
Amniotic-derived allograft injection evidence
Hanselman pilot RCT showed mixed short-term findings; policy states insufficient peer-reviewed evidence
ESWT coverage considerations
Evidence summary and typical indication thresholds for ESWT:
FDA PMA indication for ESWT devices cited
See Tung et al. (n=15 RCTs/1123) and Heide et al. (n=200 RCT) for contrasting results
PRP / Autologous blood
Platelet-rich plasma (PRP) and autologous blood injections for plantar fasciitis:
Additional well-designed long-term studies needed
de Vos et al. concluded against recommending whole blood injections
Ablative device therapies
Coblation and other device-based ablation:
510(k) clearance does not require effectiveness data
510(k) clearance cited; paucity of studies
Other therapies
Other emerging therapies (IPST, radiotherapy, stem cell therapy):
Dogramaci et al. RCT n=50 showed benefit at 6 months but small sample
Policy classifies radiotherapy as Not Medically Necessary
FDA identifies safety concerns including off-target effects and tumor risk
Coverage distinctions: ESWT vs biologics/experimental therapies
Policy contains revised coverage stance distinguishing treatments supported by evidence (e.g., ESWT per some societies) from those judged experimental or unproven (e.g., various biologics and novel devices).
Conflicting assessments from professional bodies and technology assessments are documented.
Policy revisions (5/15/2026) indicate these are addressed under experimental/unproven statements.
Each of the following interventions are designated Not Medically Necessary for the treatment of plantar fasciitis: radiotherapy, stem cell therapy, and stereotactic radiofrequency thermal lesioning. When these therapies are reported using the listed procedure codes they are considered not medically necessary; relevant codes include 28899 (unlisted procedure, foot or toes) and procedure codes associated with hematopoietic progenitor or bone marrow harvesting (e.g., 38230, 38232, 38240, 38241), and radiation delivery codes where applicable (77401 was listed prior to code deletion).
The use of amniotic‑derived allografts (e.g., cryopreserved human amniotic membrane products evaluated in pilot trials) for plantar fasciitis is not supported by sufficient peer‑reviewed evidence. A pilot randomized trial reported safety comparable to corticosteroid injection but was underpowered and authors called for further investigation; overall the policy states there is insufficient evidence in the published literature to support routine use of amniotic‑derived injectable allografts for plantar fasciitis.
Several procedures and device-based approaches lack adequate evidence to demonstrate safety and efficacy for plantar fasciitis and are considered experimental, investigational, or unproven. Examples called out in the policy include coblation® (e.g., Topaz™), intracorporeal pneumatic shock therapy (IPST), percutaneous ultrasonic ablation (e.g., Tenex), and related unlisted procedure reporting (e.g., 28899, 28890 for high‑energy ESWT depending on use). The document notes 510(k) device clearance for some technologies does not establish clinical effectiveness for this indication and published studies are few, small, or of limited follow‑up, so these modalities are considered unproven for plantar fasciitis.
Prior focused policy updates removed several previously listed modalities from the clinical statements; the 12/15/2024 focused review listed removal of statements for low‑level laser therapy (LLLT), coblation® (e.g., Topaz™), electron‑generating devices, low‑load prolonged‑duration stretch (LLPS) devices, microwave diathermy, and trigger‑point needling/infiltration of the proximal medial gastrocnemius. These removals are documented in the policy revision history and reflect prior determinations about the role of those specific device therapies in plantar fasciitis management.
The policy reiterates that the following are considered Not Medically Necessary for treatment of plantar fasciitis: radiotherapy, stem cell therapy, and stereotactic radiofrequency thermal lesioning. The policy also lists specific procedure and supply codes tied to these determinations (see Not Medically Necessary and Experimental/Investigational code groups) and clarifies that unlisted procedure codes used to report these therapies are evaluated consistent with the NMN determinations.
Evidence for platelet‑rich plasma (PRP) is heterogeneous across trials and systematic reviews. Meta‑analyses and RCTs report mixed results—some show superior medium‑term (3–6 month) pain and function improvements compared with corticosteroids, whereas short‑term and long‑term benefits are inconsistent. The literature and policy highlight high heterogeneity in PRP preparations (volume, platelet concentration, activators), inconsistent blinding, and variable comparators, limiting reproducibility and generalizability of reported benefits.
Systematic review evidence concludes that autologous whole blood injections should not be recommended for chronic tendinopathy, including plantar fasciopathy. The policy states there is insufficient evidence in the peer‑reviewed literature to support autologous whole blood injections for plantar fasciitis and therefore they are not recommended.
The policy notes a material revision effective 5/15/2026 that updated statements classifying certain treatments as Not Medically Necessary (NMN) or Experimental/Investigational/Unproven. The 5/15/2026 annual review amended the NMN and experimental treatment statements to reflect current evidence assessments for modalities such as radiotherapy, stem cell therapy, and stereotactic radiofrequency thermal lesioning, as documented in the revision history.
Coding and Clinical Thresholds
| 28899 | Unlisted procedure, foot or toes. |
| 38230 | Bone marrow harvesting for transplantation; allogeneic. |
| 38232 | Bone marrow harvesting for transplantation; autologous. |
| 38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor. |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation. |
| 77401 | Radiation treatment delivery, superficial and/or ortho voltage, per day (Code deleted 12/31/2025). |
| 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. |
| 28899 | Unlisted procedure, foot or toes. (noted for experimental uses) |
| 0232T | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed. |
| Q4100 | Skin substitute, not otherwise specified. |
| Q4139 | AmnioMatrix or BioDMatrix, injectable, 1 cc. |
| Q4155 | Neox Flo or Clarix Flo 1 mg. |
| Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc. |
| Q4192 | Restorigin, 1 cc. |
| Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg. |
| 510(k) | FDA clearance pathway referenced for PRP/platelet preparation systems |
Prior Authorization, Documentation, and Billing Expectations
Prior authorization review guidance
Prior authorization is required for advanced and biologic procedures for plantar fasciitis. Submit requests with complete clinical documentation that demonstrates prior conservative care and medical necessity. Medical directors may exercise clinical judgment; each request is reviewed against the applicable benefit plan and policy criteria.
- Prior authorization required for advanced modalities and biologic injections (e.g., PRP, amniotic-derived allografts, ESWT)
- Requests must include covered diagnosis and procedure codes current to the date of service
PRP prior authorization — document prior therapy and PRP details
For PRP prior authorization, document the conservative therapy tried and failed, the duration of symptoms, and specific PRP procedural details. Include PRP preparation method, volume injected, number of injections planned, activation method (if used), and anatomical target.
- Document prior conservative management and objective response (e.g., outcomes after ≥3 months of conservative care)
- Specify PRP system used, platelet concentration if available, volume per injection, number and timing of injections, and injection technique/location
Prior authorization: conservative therapy and symptom duration for ESWT
Prior authorization for ESWT must show that conservative therapy was exhausted and document the baseline symptom duration. ESWT is FDA-indicated for chronic proximal plantar fasciitis with symptoms ≥6 months unresponsive to conservative care; requests outside that indication carry denial risk.
- Document symptom duration (date of onset) — note if ≥6 months
- List prior conservative therapies tried and dates (see conservative sequencing)
- If indication or duration does not meet FDA-stated criteria, include rationale for medical necessity
Billing and coding documentation — use appropriate codes and date-effective code sets
Use appropriate, date-effective billing and diagnosis codes on both the prior authorization and claim. Claims lacking covered diagnosis or procedure codes referenced in the policy will be denied as not covered.
- Ensure CPT/HCPCS and ICD-10 codes reflect the service and covered diagnosis on the date of service
- Attach operative/procedural notes and documentation correlating billed codes to the service provided
Amniotic-derived allografts: evidence insufficiency (provider action/denial risk)
Evidence is insufficient to support routine use of amniotic-derived allografts for plantar fasciitis. Prior authorization requests for these products should include peer-reviewed evidence supporting use for the specific clinical scenario; absence of such evidence may result in denial.
- Document published evidence supporting intended use if requesting amniotic-derived allograft
- If no high-quality evidence is available, expect denial as experimental/investigational
Expected clinical documentation elements (prior conservative management, objective assessments)
Provide complete clinical documentation to support medical necessity: prior conservative management (with dates and objective response), duration and severity of baseline symptoms, physical exam findings, imaging if obtained, and prior injection details (agent, date, response).
- Baseline heel pain duration and localization (e.g., medial calcaneal tuberosity)
- Objective assessments: tenderness on palpation, validated pain/function scores (VAS, AOFAS, FFI-RS) and imaging reports if applicable
- Details of prior injections (corticosteroid: agent, dose, date, response) and other second-line therapies (night splint, walking cast)
Conservative therapy sequencing — exhaustion of first- and second-line therapies expected
Prior authorization reviewers expect documentation that first- and second-line conservative therapies were tried and failed before advanced or investigational treatments. Typical first-line measures include stretching, ice, footwear modification, orthoses, NSAIDs, activity modification, and physical therapy; second-line includes night splints, steroid injections, and walking casts.
- Document duration and response to first-line measures (often ≥3 months total before progressing)
- Document trials of second-line measures prior to requests for advanced therapies
Conservative therapy before biologic injections — typical trial minimum (~3 months)
Before biologic injections (PRP or amniotic products), a typical trial of conservative therapy of at least ~3 months is expected and should be documented. Prior corticosteroid injections and their outcomes should be recorded.
- Record the length and components of conservative therapy (dates and therapies)
- Document prior corticosteroid injections: agent, dose, date, and duration of benefit
Step therapy expectation — conservative measures before advanced modalities
Step therapy expectation: conservative measures should be attempted and documented prior to authorization of advanced modalities (ESWT, PRP, other biologics). Document failures of stepwise treatments to justify escalation.
- Include trial dates and objective outcomes for each step
- If requesting bypass of step therapy, provide clinical rationale and supporting documentation
Documentation supportive of ESWT requests (professional society support may be cited)
Documentation supportive of ESWT requests may cite professional society support (e.g., ACFAS) but must still show that conservative care was exhausted and symptom duration meets indication. Given mixed evidence, include trial data and rationale for ESWT in the individual patient.
- Include citations or rationale if relying on professional society recommendations
- Provide patient-specific evidence (failed prior therapies, objective pain/function scores) to support ESWT request
Clinical Background
Plantar fasciitis is an overuse condition characterized by inflammation and degeneration of the plantar fascia, a thick fibrous band connecting the heel to the forefoot. Clinically it presents with heel pain that is typically worse with the first steps in the morning or after periods of rest and may be exacerbated by prolonged weight bearing or activity. Risk factors reported in the clinical background include obesity, limited ankle dorsiflexion, increased activity, and older age; initial conservative management commonly shortens symptom duration.
Key Definitions and Terminology
Policy Revision History
Revised policy statement for not medically necessary treatments for plantar fasciitis.
No clinical policy statement changes recorded for the annual review.
Removed policy statements for several modalities including low-level laser therapy (LLLT), coblation (e.g., Topaz), electron-generating devices, low-load prolonged-duration stretch (LLPS) devices, microwave diathermy, and trigger-point needling of the proximal medial gastrocnemius.
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