Modifiedpriority healthPolicy NO. 91527

EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

Customize your policy alerts

Sign up for priority health Policy NO. 91527 alerts

Get alerted when Policy NO. 91527 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs medical necessity and coverage criteria for extracorporeal shock wave therapy, including ESWL and low-intensity ESWT, and specifies when therapy is medically necessary, not medically necessary, or experimental for Priority Health members.

Policy Summary

Payerpriority health

PolicyEXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

Policy CodePolicy NO. 91527

Change TypeMaterial coverage additions and clarifications (new indications addedexclusions updated)

Effective DateJun 1, 2026

Last ReviewMay 13, 2026

Next Review DateMay 13, 2026

Key ActionObtain prior authorization with clinical documentation showing diagnosis, stone size/location, prior treatments, or contraindication to surgery when requesting ESWL for the newly added indications.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Modifiedpriority healthPolicy NO. 91527

EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

Customize your policy alerts

Sign up for priority health Policy NO. 91527 alerts

Get alerted when Policy NO. 91527 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerpriority health

PolicyEXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

Policy CodePolicy NO. 91527

Change TypeMaterial coverage additions and clarifications (new indications addedexclusions updated)

Effective DateJun 1, 2026

Last ReviewMay 13, 2026

Next Review DateMay 13, 2026

SourceLink

POLICY UPDATE CHANGES

ESWL added as medically necessary for obstructing pancreatic duct stones (chronic pancreatitis) when specific criteria are met.

ESWL added as medically necessary for gallbladder stones (cholelithiasis) in non-surgical candidates with strict criteria.

ESWL added as medically necessary for common bile duct stones (choledocholithiasis) as last-line therapy after failure of standard and intraductal techniques.

Salivary gland or salivary duct stones designated not medically necessary.

Background and references updated to include new evidence and society guidelines.

≥5 mmPancreatic stone size threshold

<20 mmGallbladder stone max size

05/2026Policy review through

MultipleApplicable product types

Salivary stonesNew exclusion

4Added coverage items

Coverage and Medical Necessity Criteria

Medically Necessary Indications for ESWL

Covered when ALL of the following are met for each listed indication:

Renal or Ureteral Stones (Urolithiasis): ESWL may be considered medically necessary for renal or ureteral stones.

See guideline references for procedural technique and patient selection.

Obstructing Pancreatic Duct Stones (Chronic Pancreatitis): ESWL is indicated when ALL criteria are met: member has chronic pancreatitis with obstruction of the main pancreatic duct; main pancreatic duct stones >= 5 mm in size; stones located in the head or body of the pancreas; ESWL is used as first-line therapy alone or in combination with endoscopic therapy (e.g., ERCP), or when endoscopic stone extraction alone is not feasible or successful.stone size >= 5 mm

Approximately 44% of chronic pancreatitis patients may be eligible; retrospective series report ~79% stone clearance.

Gallbladder Stones (Cholelithiasis): ESWL indicated only for non-surgical members when ALL of the following criteria are met: member is not a candidate for cholecystectomy due to medical comorbidity or contraindication to surgery; presence of a single, radiolucent (cholesterol) gallstone; stone size < 20 mm; member has a functioning gallbladder with a patent cystic duct.stone size < 20 mm

Reserved for non-surgical candidates only.

Common Bile Duct Stones (Choledocholithiasis): ESWL indicated only as last-line therapy when ALL of the following have failed or are not feasible: standard ERCP-based stone extraction techniques; intraductal lithotripsy (e.g., laser or electrohydraulic lithotripsy).

ESWL is salvage therapy after failure or infeasibility of standard and intraductal approaches.

Not Medically Necessary

Not medically necessary list: Extracorporeal Shock Wave Therapy (ESWT) is not medically necessary for orthopedic or musculoskeletal applications (including but not limited to plantar fasciitis, wound healing, epicondylitis), coronary artery disease, peripheral artery disease, lymphedema, multiple sclerosis, spasticity, stress urinary incontinence, and salivary gland or salivary duct stones.

These indications are explicitly listed as not medically necessary.

Experimental / Investigational

Experimental/Investigational: Low-intensity extracorporeal shock wave therapy (Li-ESWT) is considered experimental and investigational for the treatment of erectile dysfunction.

Guideline bodies (e.g., AUA) consider Li-ESWT investigational for ED due to limited randomized, sham‑controlled data.

General coverage condition

Covered when plan benefits and any required prior authorization are satisfied and medical necessity is demonstrated to the plan reviewer

Plan and Medical Necessity: Member's specific benefits must cover the service AND medical necessity must be demonstrated when prior authorization is required.

When prior authorization is required, submit clinical documentation demonstrating medical necessity; individual case review may be needed for investigational therapies.

New Medically Necessary Indications (Additions)

Covered when specific criteria are met (per Additions section):

Pancreatic duct stones (chronic pancreatitis): ESWL is added as medically necessary for obstructing pancreatic duct stones in chronic pancreatitis when specific criteria are met (see policy): documentation of chronic pancreatitis with main pancreatic duct obstruction and qualifying stone characteristics.see full policy for criteria (e.g., stone size >= 5 mm)

Supported by guideline and literature citations; prior authorization implied.

Gallbladder stones (cholelithiasis): ESWL is added as medically necessary for gallbladder stones in non-surgical candidates with strict criteria (see policy): non-candidate for cholecystectomy, single radiolucent stone, stone <20 mm, functioning gallbladder with patent cystic duct.see full policy for criteria (e.g., stone size < 20 mm)

Intended for non-surgical candidates only; prior authorization implied.

Common bile duct stones (choledocholithiasis):

Extracorporeal Shock Wave Lithotripsy (ESWL) is not FDA approved or FDA cleared for the treatment of salivary gland or salivary duct stones. Otolaryngology and salivary gland management guidelines recommend endoscopic sialendoscopy (with or without basket retrieval or laser fragmentation) and transoral duct surgery as the preferred first-line procedural interventions; accordingly, ESWL is not recommended as the standard of care for salivary stones.

Treatments deemed experimental, investigational, or unproven are excluded from coverage unless an exception is granted through an individual case review with prior plan approval. Exceptions are considered only in limited circumstances (for example, terminal illness or severe, disabling disease with serious clinical deterioration) and require review by a Priority Health medical director or clinical pharmacist.

Extracorporeal Shock Wave Therapy (ESWT) for salivary gland or salivary duct stones is considered not medically necessary and is listed among indications for which ESWT/ESWL will not be covered.

ESWT is not medically necessary for the following non-urologic indications: orthopedic or musculoskeletal applications (including but not limited to plantar fasciitis, wound healing, and epicondylitis), coronary artery disease, peripheral artery disease, lymphedema, multiple sclerosis, spasticity, stress urinary incontinence, and other similar indications where evidence of benefit is insufficient.

The policy may exclude coverage for services that are experimental, investigational, or unproven unless a provider obtains prior plan approval via individual case review. When individual consideration is requested, prior authorization and review by a Priority Health medical director or clinical pharmacist are required to determine whether an exception is warranted.

Reiterating the coverage stance: treatment of salivary gland or salivary duct stones with ESWL is not medically necessary and may be denied when submitted for payment, consistent with guideline recommendations favoring endoscopic and transoral duct approaches.

Diagnosis and Procedure Codes

ICD-10 Codes that may support medical necessityICD-10

K80.20	Calculus of gallbladder without cholecystitis, without obstruction
K80.24	Calculus of gallbladder without cholecystitis, without obstruction, Unspecified
K80.50	Calculus of bile duct without cholangitis or cholecystitis, without obstruction
K80.51	Calculus of bile duct with cholangitis
K80.52	Calculus of bile duct with obstruction
K80.53	Calculus of bile duct with cholangitis and obstruction
K80.80	Other cholelithiasis without obstruction
K86.80	Pancreatic duct stone without pancreatic duct stenosis
K86.81	Pancreatic duct stone with pancreatic duct stenosis
K86.89	Other specified diseases of pancreas (includes Calculus of pancreas)

1–10 of 19

1/2

Procedure/CPT & HCPCS Codesmixed

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, including topical application and dressing care; 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 (Explanatory notes must accompany claim)
20999	Unlisted procedure, musculoskeletal system, general (Explanatory notes must accompany claim)

Biliary and Pancreas Unlisted CodesCPT

47999	Unlisted procedure, biliary tract
48999	Unlisted procedure, pancreas

Ureteral or Renal StonesCPTCovered

50590

Renal Lithotripsy, extracorporeal shock wave

No explicit CPT/ICD codes listed in provided sectionmixed

No codes listed

Pancreatic duct stone size threshold

Threshold>= 5 mm

ContextMain pancreatic duct stones size qualifying for ESWL in chronic pancreatitis

Location requirementStones located in head or body of the pancreas per indication criteria

Gallbladder stone maximum size for ESWL in non-surgical candidates

Threshold< 20 mm

ContextMaximum gallbladder stone size for ESWL in non-surgical candidates (single radiolucent/cholesterol stone)

Prior Authorization, Documentation, and Operational Steps

Prior Authorization

Obtain prior authorization with diagnosis and clinical criteria

Prior authorization may be required for ESWL/ESWT. Submit a prior authorization request that documents the diagnosis and the specific clinical criteria relevant to the indication (e.g., stone size and location, prior treatments or infeasibility of endoscopic approaches, surgical contraindication). Include relevant ICD-10 diagnosis codes when requesting review.

Document stone size/location and prior endoscopic or surgical attempts or contraindications.
Include one of the listed ICD-10 codes that supports medical necessity (e.g., K86.80–K86.89 for pancreatic stones; K80.x for gallbladder/bile duct stones; N20.x–N21.x for urinary stones).

Prior Authorization

Submit medical necessity and verify member benefits

When prior authorization is required, submit medical necessity documentation and verify the member’s specific benefits and plan coverage before scheduling the procedure.

Coverage is subject to the member's specific benefits and applicable plan documents.

Background and Definitions

Extracorporeal shock wave therapy (ESWT) is a noninvasive treatment that delivers focused or radial acoustic shock waves. In lithotripsy use (ESWL), shock waves are applied extracorporeally to fragment stones within ducts or the urinary tract. ESWL is commonly used for renal and proximal ureteral calculi and has been proposed or studied for obstructing pancreatic duct stones, biliary stones, and other indications; treatment parameters (for example, focused versus radial delivery, energy settings, and shockwave delivery rate) and clinical effectiveness vary by indication, with guideline recommendations and evidence supporting specific, limited uses while advising endoscopy-based, gland-preserving approaches for salivary stones.

Focused vs radial shock waves

Focused shock wavesPenetrate deeper into tissues; generated by electrohydraulic, electromagnetic, or piezoelectric technology

Radial shock wavesProduced pneumatically; deliver radially expanding, wider-area, lower-energy waves

Clinical implicationFocused devices are used when deeper tissue penetration is required; radial devices provide broader, superficial coverage

Extracorporeal Shock Wave Lithotripsy (ESWL) — definition

Policy Revision History

2026-06-01effective_dateLatest

Policy effective date for the current version.

2026-05-13last_review

Last clinical review of the policy conducted.

2026-05material_change_addition

Policy Summary

Payerpriority health

PolicyEXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)

Policy CodePolicy NO. 91527

Change TypeMaterial coverage additions and clarifications (new indications addedexclusions updated)

Effective DateJun 1, 2026

Last ReviewMay 13, 2026

Next Review DateMay 13, 2026

SourceLink

On This Page

ESWL is added as medically necessary as last-line therapy for common bile duct stones after documented failure or infeasibility of standard ERCP-based extraction and intraductal lithotripsy (e.g., laser or electrohydraulic).

failure of standard and intraductal techniques must be documented

Stepwise therapy required before ESWL; documentation should show prior attempts and rationale for ESWL.

Additional required criteriaMember not a candidate for cholecystectomy and functioning gallbladder with patent cystic duct

None specified

SpecificationNone specified in this category

NoteNo additional numeric thresholds provided in the referenced coding list

ImplicationUse clinical criteria and documented indications rather than numeric thresholds for these codes

No numeric thresholds specified

SpecificationNo numeric thresholds specified

ContextAdditions section outlines new indications but does not list numeric thresholds for some device/indication groups

ActionFollow indication-specific criteria and documentation requirements in policy text when numeric thresholds are absent

If prior authorization is required, the request must demonstrate medical necessity per the policy.

Prior Authorization

Prior authorization implied for new ESWL indications

Prior authorization is expected when ESWL is used for the newly added medically necessary indications (pancreatic duct stones, gallbladder stones in non-surgical candidates, or CBD stones) to ensure the criteria for those indications are met.

Include documentation that the added-indication criteria are met (e.g., pancreatic duct stone ≥ 5 mm; gallbladder stone < 20 mm in a non-surgical candidate; documentation of failed prior techniques for CBD stones).

Step Therapy

Reserve ESWL as last-line therapy for CBD stones

For common bile duct (choledocholithiasis) cases, ESWL is reserved as a last-line therapy after failure or inability to perform ERCP-based extraction and intraductal lithotripsy (e.g., laser or electrohydraulic). Document failure or infeasibility of those techniques before requesting ESWL.

Document attempts and outcomes of standard ERCP-based extraction techniques.
Document use of or failure of intraductal lithotripsy (laser or electrohydraulic) when performed.

Step Therapy

Stepwise requirement before ESWL for choledocholithiasis

ESWL for common bile duct stones is covered only after a stepwise progression of therapies has failed; providers must show documentation that standard ERCP techniques and intraductal approaches were attempted or were not feasible prior to ESWL.

Provide records of ERCP procedures and why standard extraction failed or was not possible.
Provide documentation of intraductal lithotripsy attempts (method and outcome) when applicable.

Documentation Required

Provide supporting clinical documentation tied to diagnosis codes

Clinical documentation must support the diagnosis codes used and demonstrate the clinical criteria required by the indication (for example, stone size, stone location, prior treatments, or contraindications to surgery).

Include imaging reports documenting stone size and location.
Include operative/endoscopic reports documenting prior attempts or reasons they were not feasible.

Prior Authorization

Submit medical necessity request and verify benefits

When prior authorization is required, submit a request demonstrating medical necessity; coverage determinations remain subject to the member’s plan benefits and applicable plan documents.

Requests for individual case review of investigational therapies require prior plan approval.
Confirm coverage applicability for the member’s specific product (HMO/EPO, PPO, ASO, Medicare, Medicaid, etc.).

Documentation Required

Document criteria for new medically necessary indications

For the newly added coverage indications, supply documentation that ESWL is being used specifically for obstructing pancreatic duct stones in chronic pancreatitis, gallbladder stones in non-surgical candidates meeting strict criteria, or common bile duct stones only after failure of standard and intraductal techniques.

For pancreatic stones: document chronic pancreatitis diagnosis and main pancreatic duct stones ≥ 5 mm.
For gallbladder stones: document non-surgical candidacy, single radiolucent stone < 20 mm, and a functioning gallbladder with patent cystic duct.
For CBD stones: document failure/infeasibility of ERCP and intraductal lithotripsy.

Denial Risk

Avoid requests for not medically necessary indications

Do not request ESWT/ESWL for indications listed as not medically necessary (including orthopedic/musculoskeletal uses, coronary or peripheral artery disease, lymphedema, multiple sclerosis, spasticity, stress urinary incontinence, and salivary gland or salivary duct stones); such requests may be denied.

Salivary gland and salivary duct stones are specifically listed as not medically necessary.

Denial Risk

Risk of denial for experimental/investigational indications

Coverage for experimental, investigational, or unproven ESWT indications (e.g., low-intensity ESWT for erectile dysfunction) may be denied unless an individual case review with prior plan approval is obtained; exceptions are considered only in limited circumstances (terminal illness or severe, disabling disease with serious clinical deterioration).

Requests for individual consideration require prior plan approval and review by a Priority Health medical director or clinical pharmacist.
Provide supporting evidence if requesting an investigational exception.

Denial Risk

Denial risk for salivary gland or duct stones

Requests for ESWL/ESWT to treat salivary gland or salivary duct stones may be denied because these indications are designated not medically necessary and ESWL is not FDA approved/cleared for salivary gland or duct stones.

Preferred first-line interventions for sialolithiasis are endoscopic sialendoscopy and transoral duct surgery rather than ESWL.
Do not submit ESWL requests for salivary gland/duct stones unless pursuing an individual case review with prior plan approval.

DefinitionExtracorporeal Shock Wave Lithotripsy (ESWL): use of shock waves to fragment stones in the urinary tract or other ducts

Treatment settingNoninvasive outpatient procedure often performed with local or regional anesthesia

IndicationsUsed for renal/ureteral stones and, per policy additions, selected biliary and pancreatic duct stones when criteria met

CPT 50590 (renal lithotripsy)

CodeCPT 50590 — Renal Lithotripsy, extracorporeal shock wave

ContextListed in coding section for ureteral or renal stones (covered group)

Usage noteUse CPT 50590 for renal/ureteral ESWL procedures per policy coding

0864T (Category III code for low-intensity ESWT)

Code0864T — Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy

CategoryHCPCS/CPT Category III code (temporary); associated with erectile dysfunction applications

Policy statusLi-ESWT (including uses coded with 0864T) considered experimental/investigational for erectile dysfunction in this policy

ESWL (general definition for biliary, pancreatic, salivary, urinary stones)

DefinitionESWL: noninvasive shock-wave technique used to fragment stones in biliary, pancreatic, salivary, or urinary tracts

MechanismDelivers focused or radial acoustic shock waves that fragment calculi for subsequent clearance or extraction

Common usesRenal/ureteral stones; selected pancreatic duct, gallbladder, and common bile duct stones per policy criteria

Added ESWL as medically necessary for obstructing pancreatic duct stones (chronic pancreatitis) when specific criteria are met.

2026-05material_change_addition

Added ESWL as medically necessary for gallbladder stones (cholelithiasis) in non-surgical candidates with strict criteria.

2026-05material_change_addition

Added ESWL as medically necessary for common bile duct stones (choledocholithiasis) as last-line therapy after failure of standard and intraductal techniques.

2026-05material_change_addition

Designated salivary gland or salivary duct stones as not medically necessary (added exclusion).

2026-05references_updated

Background and reference citations refreshed to include new evidence and society guidelines.