CurrentColorado Rocky Mountain Health PlansPolicy CS041.U

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications – Community Plan Medical Policy

Defines the medical policy stance of Colorado Rocky Mountain Health Plans (Community Plan) on extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications, lists applicable CPT/T proprietary codes for reference, summarizes clinical evidence across indications, and excludes ESWL for stones. This part (1 of 3) contains coverage rationale, descriptions, and evidence summaries for multiple indications.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications – Community Plan Medical Policy

Policy CodePolicy CS041.U

Change TypeTitle and state-specific application updatesadministrative/template revisions

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders should expect claims for ESWT for musculoskeletal and soft tissue indications to be non-covered per this policy and follow contractual/state exceptions where applicable.

SourceLink

POLICY UPDATE CHANGES

Title updated 11/01/2025 to include 'and Soft Tissue Wounds' and state-specific applicability notes added for Nebraska and North Carolina.

Multiple state-specific application/reference link updates on 12/01/2025, 01/01/2026, 02/01/2026, and 04/01/2026; template update removed Louisiana-specific content on 04/01/2026.

04/01/2026 Template Update removed content/language pertaining to the state of Louisiana; application Kentucky updated reference link for state-specific version.

02/01/2026 Application Idaho updated reference link to reflect current title for state-specific policy version.

01/01/2026 Application Louisiana and Ohio updated reference link to reflect current title for state-specific policy version.

12/01/2025 Application Kansas updated reference link to reflect current title for state-specific policy version.

11/01/2025 Title change from 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds' and added language that the policy does not apply to Nebraska and North Carolina; supporting information updated (Clinical Evidence and References); previous policy version CS041.T archived.

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1Overall coverage stance (not medically necessary)

7Procedure codes listed for reference

multipleIndications discussed in this part

severalSystematic reviews/meta-analyses cited

randomized trialsRCTs cited

5Recent revision entries

Coverage Summary

Policy statement: Extracorporeal shock wave therapy (ESWT), whether low energy, high energy, or radial wave, is considered unproven and not medically necessary for any musculoskeletal or soft tissue indications. This policy explicitly excludes extracorporeal shock wave lithotripsy (ESWL) for stone indications (gallstones, kidney stones, pancreatic stones, salivary stones) from its scope. Policy number: CS041.U. Effective date: November 1, 2025.

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity Determination

ALL of the following

Extracorporeal shock wave therapy (ESWT), whether low energy, high energy, or radial wave, is unproven and not medically necessary for any musculoskeletal or soft tissue indications due to insufficient evidence of efficacy.
This policy does not address extracorporeal shock wave lithotripsy (ESWL) used for treatment of gallstones, kidney stones, pancreatic stones, or salivary stones.

Evidence assessment by indication

Summarized conclusions and evidence strength for specific indications based on systematic reviews, meta-analyses, and RCTs:

ALL of the following

Lateral epicondylitis (tennis elbow): Evidence mixed — multiple systematic reviews and RCTs show variable results; some meta-analyses suggest ESWT inferior to corticosteroid injection at 1 month but superior at 3 and 6 months for pain (VAS), grip strength, and PRTEE in some analyses; other RCTs and meta-analyses show no superiority over sham or alternative therapies. Limitations: heterogeneity of devices, protocols, small sample sizes, variable follow-up.
Refractory greater trochanteric pain syndrome (GTPS): Evidence inconclusive/insufficient — systematic reviews report moderate but heterogeneous effects; one RCT (Ramon et al. 2020) reported benefit with focused ESWT plus home exercise, but further high-quality RCTs needed.
Tenosynovitis of the foot or ankle: No clinical studies identified evaluating ESWT for this indication.

Coding (reference only)

Applicable Procedure Codes (reference only)CPT

0101T	Extracorporeal shock wave involving musculoskeletal system, not otherwise specified.
0102T	Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle.
0512T	Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial wound.
0513T	Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure).
0864T	Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy.
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.

FDA device classification (informational)mixed

NBN	FDA product code: generator, shock-wave, for pain relief (Class III devices via PMA)

Provider Actions & Administrative Guidance

Prior Authorization

Prior authorization implication

ESWT claims for musculoskeletal and soft tissue indications are expected to be non‑covered per this policy. Prior authorization implication: providers should anticipate denials for services that do not meet state/contractual exceptions or approved medical necessity criteria. Verify benefits and submit any required prior authorization requests where applicable.

0101T
0102T
0512T
0513T
0864T
28890

Prior Authorization

Prior authorization implied by policy context

Clinical review and authorization may be required in some jurisdictions or under some contracts. Verify whether a state‑specific policy or contract exception applies before submitting claims; if a state policy applies it may supersede this community plan policy.

Background and Definitions

Background: ESWT devices produce acoustic shock waves (low- or high-energy) that may be focused or radial and are propagated through tissues; orthopedic applications typically use about ten times less energy than lithotripsy devices, and low-energy defocused ESWT is used for wound healing. Proposed mechanisms include direct mechanical effects (rapid positive pressure) and indirect effects (bubble implosion) that might reduce pain transmission, disintegrate calcium deposits, break down scar tissue, provoke transient inflammation, and stimulate tissue healing, but the therapeutic mechanism is not established. ESWT products are regulated as Class III medical devices (product code NBN) by the FDA. Clinical evidence across indications is heterogeneous with variation in device type (focused vs radial), energy settings, dosing and protocols, and study designs, limiting generalizability.

Term	Definition
ESWT
Extracorporeal shock wave therapy — therapeutic acoustic shock waves applied to musculoskeletal or soft tissue targets; may be low- or high-energy, focused or radial. Devices produce low- or high-energy pulses (shock waves) that can be focused or defocused; mechanisms proposed include mechanical effects and stimulation of tissue healing, though mechanisms are not fully established.
ESWL
Extracorporeal shock wave lithotripsy — shock waves used to break up stones (gallstone, kidney, pancreatic, salivary); this policy does not address ESWL.
Focused vs radial (within ESWT)
Focused (f-ESWT) and radial devices — ESWT may be delivered as focused or radial shock waves with variable energy settings and protocols; clinical studies and recommendations note heterogeneity between focused and radial technologies and differing energy (low vs high) used for indications such as orthopedic conditions and wound healing.
DFU
Diabetic foot ulcer (DFU) — chronic wound of the foot in patients with diabetes; ESWT (including devices with De Novo FDA clearance such as dermaPACE for DFUs) has been studied for DFU healing with randomized trials and meta-analyses showing improved complete healing rates and shorter time to closure versus standard care or hyperbaric oxygen in pooled analyses, though studies are heterogeneous and further high-quality trials are recommended.

Evidence Summary by Indication

Lead-in: Conclusions in this policy are based on systematic reviews, meta-analyses, and randomized controlled trials across multiple indications. The body of evidence is marked by substantial heterogeneity in devices (focused vs radial), energy and dosing parameters, study sizes, follow-up durations, and risk of bias; these limitations affect the strength and consistency of outcomes and informed the determination that ESWT is unproven and not medically necessary for musculoskeletal and soft tissue indications.

Revision History

11/01/2025revisedLatest

Title changed from 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds'; policy effective date set to November 1, 2025; added language that the policy does not apply to Nebraska and North Carolina; supporting information and references updated; previous policy version CS041.T archived. Note: is_material = false.

12/01/2025revised

Application Kansas updated reference link to reflect current title for state-specific policy version. Note: is_material = false.

01/01/2026

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications – Community Plan Medical Policy

Policy CodePolicy CS041.U

Change TypeTitle and state-specific application updatesadministrative/template revisions

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders should expect claims for ESWT for musculoskeletal and soft tissue indications to be non-covered per this policy and follow contractual/state exceptions where applicable.

SourceLink

On This Page

Tibialis tendonitis: No clinical studies identified evaluating ESWT for this indication.

Wounds (including diabetic foot ulcers and acute/chronic soft tissue wounds): Evidence suggests promise — multiple systematic reviews/meta-analyses and RCTs report improved healing rates, shorter time to closure, and increased complete healing for DFUs and other soft tissue wounds compared with standard care or HBOT in pooled analyses; however, studies are heterogeneous, often small, and authors recommend further high-quality trials. dermaPACE device has FDA De Novo clearance for DFUs.

General limitations across indications: Heterogeneous ESWT devices (focused vs radial), varied energy settings/protocols, inconsistent follow-up durations, small sample sizes, potential bias in many studies; need for standardized protocols and larger RCTs.

Documentation Required

Documentation expectations

Document the indication‑specific clinical rationale and the conservative therapies tried and failed. Include device specifics (device type: radial vs focused, manufacturer), energy settings, number and timing of sessions, and the expected treatment protocol to support medical necessity determinations.

Documentation Required

Check state/contract and use decision tools

Verify federal, state, and contractual benefit requirements and the applicability of any state‑specific policy before rendering or billing for ESWT. Use available evidence, device details, and authorized decision‑support tools (for example, InterQual or other third‑party clinical criteria) to support determinations and authorization requests. Check the specific state versions of this policy where noted.

States with state‑specific guidance: Idaho, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee, Indiana
Recommendation: Check the state‑specific policy/guideline and contract benefits for applicability and any differing coverage rules

Application Louisiana and Ohio updated reference link to reflect current title for state-specific policy version. Note: is_material = false.

02/01/2026revised

Application Idaho updated reference link to reflect current title for state-specific policy version. Note: is_material = false.

04/01/2026revised

Template update removed content/language pertaining to the state of Louisiana; Application Kentucky updated reference link for state-specific version. Note: is_material = false.

clarified

Archived prior policy version CS041.T; supporting information and references updated. Note: is_material = false.