Modifiedpriority healthPolicy N/A

Extracorporeal Shock Wave Therapy (ESWT)

This policy governs use and coverage of extracorporeal shock wave therapies (including ESWL and low-intensity ESWT) for Priority Health members, specifying medically necessary indications and treatments considered not medically necessary or experimental.

Policy Summary

Payerpriority health

PolicyExtracorporeal Shock Wave Therapy (ESWT)

Policy CodePolicy N/A

Change TypeMaterial updates — added ESWL as medically necessaryexpanded non-covered ESWT services

Effective DateMar 1, 2026

Next Review Date

Key ActionWhen prior authorization is required, submit medical necessity documentation per Priority Health provider requirements.

SourceLink

POLICY UPDATE CHANGES

Added Extracorporeal Shock Wave Lithotripsy as medically necessary for treatment of urolithiasis.

Added additional non-covered services for extracorporeal shock wave therapy (ESWT).

New Medical/Professional Society Guidelines, Government Regulations, FDA/Regulatory, and Policy Scope sections were added.

Policy was restructured to first specify inclusion (lithotripsy) and second specify ESWT conditions that are not medically necessary.

1Medically necessary indication added

7Not medically necessary conditions

1Experimental listing (Li-ESWT for ED)

9Procedure/HCPCS codes

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Coverage Criteria for Extracorporeal Shock Wave Therapies

Extracorporeal Shock Wave Lithotripsy (ESWL) - Medically Necessary

Covered when the following is met

ESWL for urolithiasis: Extracorporeal Shock Wave Lithotripsy (ESWL) may be considered medically necessary for the treatment of urolithiasis.

See A. in medical necessity criteria; use slow shockwave delivery strategy and start with low-energy shocks for kidney stones per guideline guidance [[chunk 11]]

Extracorporeal Shock Wave Therapy (ESWT) - Not Medically Necessary

Not medically necessary for the following conditions

ESWT Not Medically Necessary Conditions: Extracorporeal Shock Wave Therapy (ESWT) is not medically necessary for the following conditions: orthopedic or musculoskeletal applications (including but not limited to plantar fasciitis, wound healing, epicondylitis of the elbow); coronary artery disease; peripheral artery disease; lymphedema; multiple sclerosis; spasticity; stress urinary incontinence.

See B. in medical necessity criteria

Low-intensity ESWT (Li-ESWT) - Experimental/Investigational

Considered experimental/investigational

Li-ESWT for Erectile Dysfunction: Low-intensity extracorporeal shockwave therapy (Li-ESWT) is considered experimental and investigational for the treatment of erectile dysfunction.

See C. in medical necessity criteria; evidence is limited by small heterogeneous cohorts and lack of robust randomized sham-controlled trials [[chunk 11]]

Coverage under this policy is determined by the member's specific benefits and applicable plan documents. Member benefits and group-specific policy provisions supersede this medical policy when there is a conflict. Providers should consult the individual plan or contract (for HMO/EPO, POS, PPO, ASO/self-funded, individual, Medicare, and Medicaid/Healthy Michigan Plan products) to confirm coverage specifics before rendering services.

A systematic review specifically addressing plantar fasciitis reports both effectiveness studies and pooled analyses for extracorporeal shock wave therapy and also summarizes adverse events. When evaluating ESWT for plantar fasciitis, consider the documented complications and safety data described in that review as potentially relevant contraindications or risks to coverage.

The references section lists randomized trials, systematic reviews, and guideline citations relevant to ESWT and related indications (for example, spasticity, stress urinary incontinence, and kidney/ureteral stones). These chunks present citations only and do not on their own state explicit coverage exclusions or requirements; they should be used as supporting evidence when preparing clinical documentation or prior authorization requests.

Priority Health considers Extracorporeal Shock Wave Therapy (ESWT) not medically necessary for orthopedic and musculoskeletal indications, including but not limited to plantar fasciitis, wound healing, and epicondylitis of the elbow, due to insufficient evidence of effectiveness. ESWT is also considered not medically necessary for coronary artery disease, peripheral artery disease, lymphedema, multiple sclerosis, spasticity, and stress urinary incontinence.

The cited chunks do not contain additional explicit 'not medically necessary' statements beyond those summarized elsewhere in the policy. They provide supporting literature (systematic reviews, randomized controlled trials, and a guideline) that inform the policy stance but do not themselves add new coverage determinations.

Procedure and Diagnosis Codes

Procedure/CPT/HCPCS CodesCPT

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, high energy; each additional wound
0864T	Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy
28890	Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
28899	Unlisted procedure, foot or toes
20999	Unlisted procedure, musculoskeletal system, general
50590	Lithotripsy, extracorporeal shock wave

ICD-10 Codes that may support medical necessityICD-10

N20.0	Calculus of kidney
N20.1	Calculus of ureter
N20.2	Calculus of kidney with calculus of ureter
N20.9	Urinary calculus, unspecified
N21.0	Calculus in bladder
N21.1	Calculus in urethra
N21.8	Other lower urinary tract calculus
N21.9	Calculus of lower urinary tract, unspecified

CPT/HCPCS/ICD codesmixed

No codes listed

No codes provided in this sectionmixed

none	No CPT/HCPCS/ICD-10 codes are listed in these chunks.

Shockwave delivery strategy — operational note to use slow delivery and start low-energy for stones

Operational recommendationUse a slow shockwave delivery strategy and begin with low-energy shockwaves, gradually increasing energy during shockwave lithotripsy (ESWL) to optimize stone clearance and reduce bleeding risk.

Procedure contextApplies to shockwave lithotripsy (ESWL) for renal and proximal ureteral calculi where SWL is performed.

Clinical rationaleSlow delivery and low initial energy improve stone clearance and minimize complications such as bleeding, per AUA guideline referenced in policy.

Action for providersWhen documenting prior authorization or operative notes, specify the use of slow shockwave delivery and initial low-energy settings per guideline recommendation.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Supporting Evidence

Prior authorization may be required for certain ESWT services. When prior authorization is required, providers must submit a request demonstrating that the drug, device, service, or procedure is medically necessary. Coverage decisions for experimental, investigational, or unproven treatments (including requests for individual consideration) will be made by a Priority Health medical director or clinical pharmacist; individual case review may allow coverage in select serious or terminal conditions.

Submit medical necessity documentation per Priority Health Provider Manual
Coverage is subject to member benefits and plan documents
Requests for individual consideration require prior plan approval

Note

Randomized-Controlled Clinical Study Citation

Include relevant randomized-controlled clinical study citations in prior authorization or medical necessity documentation when applicable. For example, for low-intensity ESWT in stress urinary incontinence, cite: Lin K-L et al., Low Intensity Extracorporeal Shock Wave Therapy as a Novel Treatment for Stress Urinary Incontinence: A Randomized-Controlled Clinical Study. Medicina. 2021;57(9):947. https://doi.org/10.3390/medicina57090947

Background on Shock Wave Therapies

Extracorporeal shock wave therapies deliver focused or radial acoustic shock waves noninvasively. ESWL (Extracorporeal Shock Wave Lithotripsy) uses higher-energy shock waves to fragment urinary calculi and is addressed separately from ESWT used for musculoskeletal or soft-tissue conditions. ESWT encompasses a range of energy settings, including low-intensity ESWT (Li-ESWT), which has been proposed for indications such as erectile dysfunction and stress urinary incontinence but lacks consistent, high-quality evidence and is considered experimental/investigational for ED. For stone management, clinical guidance recommends beginning with low-energy shocks and a slow delivery strategy to optimize clearance and reduce bleeding risk.

Definitions and Terminology

ESWL — Extracorporeal Shock Wave Lithotripsy definition

DefinitionExtracorporeal Shock Wave Lithotripsy (ESWL) is a safe, noninvasive procedure using shock waves to fragment urinary calculi located in the kidneys or ureters, favored for renal and proximal ureteral calculi.

MechanismUses focused or propagated acoustic shock waves transmitted through tissue to fragment calculi for noninvasive management.

SettingPerformed in an outpatient setting; may reduce need for invasive surgery for urolithiasis.

Li-ESWT — Low-intensity Extracorporeal Shock Wave Therapy definition

DefinitionLow-intensity Extracorporeal Shock Wave Therapy (Li-ESWT) is a lower-energy form of ESWT proposed for conditions such as erectile dysfunction and other pelvic floor indications.

Evidence note