CurrentUnitedHealthcarePolicy CS041ID.B

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for Idaho Only)

Policy applies only to the state of Idaho, including Idaho Medicaid Plus plans, and addresses use of extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications (excluding ESWL for stones). It defines the coverage stance based on available evidence for multiple indications (Achilles tendinopathy, rotator cuff/calcific tendinitis, plantar fasciitis, delayed/nonunion fractures, erectile dysfunction, lateral epicondylitis, hammer toe).

Policy Summary

PayerUnitedHealthcare

PolicyExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for Idaho Only)

Policy CodePolicy CS041ID.B

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review Date

Key ActionConfirm member is enrolled in a UnitedHealthcare plan in Idaho (including Idaho Medicaid Plus) before applying this ESWT policy.

SourceLink

POLICY UPDATE CHANGES

There are no material clinical or coverage changes in this update; policy remains a determination that ESWT is unproven and not medically necessary for musculoskeletal or soft tissue indications.

1States covered (Idaho only)

6Procedure codes listed

8Indications discussed in evidence section

Coverage Summary

Policy applies only to the state of Idaho (including Idaho Medicaid Plus). Based on review of systematic reviews, randomized trials, and guideline positions across multiple musculoskeletal and soft tissue indications, the policy stance is that extracorporeal shock wave therapy (ESWT) is unproven and not medically necessary for musculoskeletal and soft tissue indications.

Extracorporeal shock wave therapy (ESWT), including low-energy, high-energy, and radial wave devices, is considered 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) for gallstones, kidney stones, pancreatic stones, or salivary stones.

Medical Necessity / Coverage Determination

General Coverage Determination

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.

Procedure Codes

Procedure codes referencedCPT

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.

Provider Actions & Billing Impact

Documentation Required

State-specific applicability

Confirm member is enrolled in a UnitedHealthcare plan in Idaho (including Idaho Medicaid Plus) before applying this ESWT policy.

Applies to UnitedHealthcare Idaho plans including Idaho Medicaid Plus

Denial Risk

Not medically necessary determination

Claims for ESWT for any musculoskeletal or soft tissue indication in Idaho are considered unproven and not medically necessary per this policy and are at risk for denial.

0101T
0102T
0512T
0513T
0864T
28890
Claims for ESWT for any musculoskeletal or soft tissue indication in Idaho are at risk for denial.

Background & Evidence Summary

ESWT devices produce acoustic shock waves (low- or high-energy) that can be focused or radial; orthopedic applications use the same type of shock waves as lithotripters but at about one-tenth the energy and may be delivered as defocused/soft acoustic waves for wound healing. Proposed mechanisms include direct mechanical effects from rapid positive pressure buildup and indirect effects from bubble implosion in interstitial fluid, which may reduce pain signaling, disrupt calcifications or scar tissue, and stimulate a transient inflammatory or healing response. The available evidence across indications is insufficient to support medical necessity for ESWT in musculoskeletal and soft tissue conditions.

Indication	Evidence summary
Overall policy conclusion	ESWT is considered unproven and not medically necessary for any musculoskeletal or soft tissue indications due to insufficient evidence of efficacy.
Achilles tendinopathy evidence	Multiple systematic reviews and small RCTs with low to very low quality; inconsistent findings and no adequate prospective clinical studies demonstrating effectiveness.
Calcific rotator cuff tendinitis evidence	Some RCTs and systematic reviews suggest high-energy ESWT may improve pain/function for some patients, but evidence quality is low and findings are conflicting; further standardized trials needed.
Plantar fasciitis evidence	RCTs and meta-analyses report conflicting and heterogeneous results; some trials show short- to mid-term benefit but methodological limitations and inconsistency across studies.
Delayed/nonunion fractures evidence	Systematic reviews show heterogeneous data and variable union rates; evidence quality low and high-quality RCTs are lacking.
Erectile dysfunction evidence	Multiple RCTs and meta-analyses with substantial heterogeneity; some analyses show improvement but guideline recommendations are conflicting and ESWT often considered investigational.
Lateral epicondylitis evidence	Conflicting and inconsistent evidence: some analyses show short-term inferiority versus corticosteroid injection but possible longer-term benefit; study heterogeneity and mixed RCT results.

Scope & Exclusions

Scope limited to Idaho only (including Idaho Medicaid Plus) and excludes ESWL for stone fragmentation (gallstones, kidney stones, pancreatic, salivary). This policy addresses multiple musculoskeletal and soft tissue indications discussed in the evidence (for example: Achilles tendinopathy, calcific rotator cuff tendinitis, plantar fasciitis, delayed/nonunion fractures, erectile dysfunction, lateral epicondylitis, hammer toe, wounds) but does not cover ESWL lithotripsy for stones.