CurrentUnitedHealthcarePolicy CSNCT0269.04

Extracorporeal Shock Wave Therapy Nc Cs

UnitedHealthcare Community Plan medical policy (North Carolina only) addressing coverage and medical necessity of extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications, summarizing evidence by indication and listing applicable procedure codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicyExtracorporeal Shock Wave Therapy Nc Cs

Policy CodePolicy CSNCT0269.04

Change TypeTemplate update; state-specific version created; evidence/references updated

Effective DateNov 1, 2025

Next Review Date

Key ActionConfirm member is in North Carolina before applying this policy; the policy applies only to North Carolina.

SourceLink

POLICY UPDATE CHANGES

Template Update and creation of state-specific policy version for North Carolina; supporting information and clinical evidence and references updated.

Created state-specific policy version for the state of North Carolina and updated title from 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds'.

Summary of Changes entry dated 11/01/2025 indicates a template update and supporting information updates.

Not coveredCoverage stance

NC onlyGeographic scope

~10

DFU RCTs/meta-analyses cited

MixedOverall evidence strength

UpdatedReference updates

Coverage Summary & Policy Scope

Scope summary: UnitedHealthcare Community Plan medical policy (North Carolina only) addressing coverage and medical necessity of extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications. Policy number: CSNCT0269.04. Effective date: November 1, 2025.

Coverage stance: This policy applies only to North Carolina and states that ESWT (low energy, high energy, or radial wave) for any musculoskeletal or soft tissue indication is considered unproven and not medically necessary due to insufficient evidence of efficacy; services may be denied under this policy.

Key facts (policy-level)

Coverage stanceESWT considered unproven and not medically necessary for all musculoskeletal and soft tissue indications (not covered)

Geographic scopeApplies only to North Carolina

Indications referencedMultiple indications discussed including lateral epicondylitis, GTPS, diabetic foot ulcers (DFU), plantar fasciitis, calcific rotator cuff, Achilles tendinopathy, delayed/nonunion fractures, erectile dysfunction, wounds and burns

Approx. RCTs/meta-analyses for DFU citedAbout 10 RCTs/meta-analyses referenced for DFU

Overall evidence strengthMixed — evidence ranges from promising (DFU, some wounds) to low/conflicting or insufficient (many musculoskeletal indications); larger high‑quality RCTs needed

Medical Necessity Determination & Exclusions

Medical Necessity Determination

Covered when ALL of the following are met:

State-specific applicability: This policy applies only to the state of North Carolina (policy is state-specific).
Policy conclusion: 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 due to insufficient evidence of efficacy.
Therefore ESWT is not covered for those indications under this policy.

Evidence Summary and Clinical Conclusions

Extracorporeal shock wave therapy (ESWT) devices generate acoustic shock waves — produced as low- or high-energy pulses that can be focused or radial — and are similar to lithotripters used to fragment kidney stones but typically deliver about one-tenth the energy for orthopedic indications. Low-energy defocused or soft focused acoustical wave patterns are used in wound healing applications.

The mechanism of therapeutic effect is not established; proposed mechanisms include direct mechanical effects (rapid positive pressure buildup and bubble implosion in interstitial fluid), reduction of pain signal transmission, disintegration of calcium deposits, breakdown of scar tissue, a transient inflammatory response, and stimulation of tissue healing/angiogenesis and improved tissue perfusion.

Evidence quality and optimal treatment parameters (device type, energy flux density, number of sessions, dosing intervals, and guidance/adjunctive protocols) remain uncertain across indications, with heterogeneity in devices and protocols and a need for larger, well-designed RCTs to determine clinical efficacy and optimal parameters.

Evidence-based conclusions and guidance (narrative)

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Evidence summaries by indication

Relevant Procedure & Device Codes (reference only)

Referenced Procedure Codes (for reference only)CPT|HCPCS|mixed

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 product code (informational)mixed

NBN	FDA product code: generator, shock-wave, for pain relief (PMA class III device)

Actionable Requirements & Denial Risks

Documentation Required

State-specific applicability

Confirm member is in North Carolina before applying this policy; the policy applies only to North Carolina.

Denial Risk

Services considered not medically necessary

Extracorporeal shock wave therapy (ESWT) for any musculoskeletal or soft tissue indication is considered unproven and may be denied as not medically necessary.

0101T
0102T
0512T
0513T
0864T
28890

Definitions

ESWT: Extracorporeal shock wave therapy — device-based therapy delivering shock waves (low energy, high energy, focused or radial) to target musculoskeletal or soft tissues.

ESWL: Extracorporeal shock wave lithotripsy — shock wave treatment for stones (gallstones, kidney stones, pancreatic stones, salivary stones); not addressed by this policy.

DFU: Diabetic Foot Ulcer — referenced in the policy as an indication discussed in evidence summaries for wound healing.

GTPS: Greater Trochanteric Pain Syndrome — referenced in the policy as a musculoskeletal indication evaluated in trials and reviews.

Device classification: ESWT products are classified by the U.S. Food and Drug Administration as Class III devices (PMA) under product code NBN — generator, shock-wave, for pain relief.

Policy Revision History

11/01/2025revised (template/state-specific/title/references)Latest

Template update and creation of a state-specific policy version for North Carolina; title changed (previously titled 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds'); supporting information with Clinical Evidence and References sections updated; previous policy version CS041.T archived.

clarified (supporting information updated)Latest

Summary of Changes entry indicates Clinical Evidence and References sections were updated to reflect current information (supporting information updated for the state-specific policy).

Policy Summary

PayerUnitedHealthcare

PolicyExtracorporeal Shock Wave Therapy Nc Cs

Policy CodePolicy CSNCT0269.04

Change TypeTemplate update; state-specific version created; evidence/references updated

Effective DateNov 1, 2025

Next Review Date

Key ActionConfirm member is in North Carolina before applying this policy; the policy applies only to North Carolina.

SourceLink

On This Page

Overall policy conclusion

Insufficient evidence of efficacy; ESWT is unproven and not medically necessary for musculoskeletal/soft tissue indications

Diabetic foot ulcers (DFU)Multiple RCTs/meta-analyses (n≈10) report higher complete healing (RR 1.57) and improved TcPO2 with ESWT; evidence promising but limited by heterogeneity and small trials

Wounds (acute/chronic)Meta-analyses report increased healing rates (OR 3.73) and reduced healing time versus conventional wound therapy; evidence limited by study quality

Lateral epicondylitisConflicting data: inferior to corticosteroid at 1 month but superior at 3–6 months for pain, grip strength, PRTEE in some meta-analyses; overall mixed

Calcific rotator cuff (calcific tendinitis)Some RCTs and systematic reviews show high‑energy ESWT may improve pain/function; overall evidence low-to-moderate and conflicting; NICE recommends use in research only

Plantar fasciitisRCTs and meta-analyses mixed; some trials favor focused/high‑energy or radial ESWT at 3–6 months, but results and quality vary

Achilles tendinopathySystematic reviews of few RCTs show very low–to low‑quality evidence with conflicting results; no strong recommendation

Delayed/nonunion fracturesLimited, heterogeneous evidence; reported union rates variable (65–100% in series); high‑quality RCTs lacking

Erectile dysfunctionMixed guideline and meta-analysis conclusions; some meta-analyses show improved IIEF-EF (MD ~2.28) but heterogeneity and low confidence limit routine use

Greater trochanteric pain syndrome (GTPS)Insufficient quality evidence overall; some RCTs (e.g., Ramon 2020) report favorable short‑term outcomes for focused ESWT plus exercise but require confirmation

Documentation Required

Documentation and benefit-term references

Document the clinical indication, prior conservative treatments and their durations, treatment response, and specific ESWT parameters (energy level, number of treatments, treatment intervals, device type and settings) in the medical record. Also reference the member's federal, state, and contractual benefits which govern coverage and medical necessity determinations.

Document indication, prior treatments, and duration
Document treatment response and ESWT parameters (energy, number of treatments, intervals, device type/settings)
Reference member's federal, state, and contractual benefits

Documentation Required

Use clinical judgment and external tools

UnitedHealthcare may use clinical review tools and third-party criteria (for example, InterQual) to inform determinations. This policy is informational; use clinical judgment and applicable external tools when evaluating medical necessity.