Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for New Mexico Only)

Coverage Summary

Scope: This policy applies only to the state of New Mexico and addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal conditions and soft tissue wounds. Applicable procedure codes (examples) are listed in the policy (e.g., 0101T, 0102T, 0512T, 0513T, 0864T, 28890), and CPT code 0864T was added in the 12/01/2024 update.

Coverage stance: ESWT (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. The policy explicitly excludes extracorporeal shock wave lithotripsy (ESWL) for stone fragmentation (kidney, gallbladder, pancreatic, salivary stones) from its scope.

Key Facts

State limitationPolicy applies only to New Mexico

Policy NumberCSO4INMB

Effective DateDecember 1, 2024

Number of procedure codes listed6

Covered indications count0

Evidence strength summaryInsufficient/Variable

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity

Extracorporeal shock wave therapy (ESWT) is unproven and not medically necessary for any musculoskeletal or soft tissue indications due to insufficient evidence of efficacy:

Unproven for musculoskeletal/soft tissue indications: ESWT (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.
State limitation: Policy applies only to the state of New Mexico.
Exclusion - lithotripsy (ESWL): This policy does not address extracorporeal shock wave lithotripsy (ESWL) used for treatment of kidney stones, gallstones, pancreatic stones, or salivary stones.

Procedure Codes

Procedure codes referencedmixed

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.
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.

CPT codes added in revision historyCPT

0864T

Extracorporeal shock wave therapy (ESWT) code added to policy (supporting information updated 12/01/2024)

Provider Actions & Billing Impact

Denial Risk

Not medically necessary determination

Claims for ESWT for musculoskeletal or soft tissue indications may be denied as not medically necessary due to insufficient evidence of efficacy.

0101T
0102T
0512T
0513T
0864T
28890

Documentation Required

Evidence and protocol variability

Because study heterogeneity (device type, energy level, number of sessions) affects outcomes, document the device used, energy settings, number of sessions, and prior conservative therapies when submitting for coverage or prior authorization.

Background & Evidence Summary

Background: ESWT devices deliver acoustic shock waves (low- or high-energy pulses) that can be focused or defocused (including radial waveforms). Devices produce shock waves that propagate through tissue; orthopedic ESWT uses pulses with approximately one-tenth the energy used for stone lithotripsy. Although the therapeutic mechanism is not established, proposed effects include direct mechanical forces (positive pressure and cavitation/implosion of bubbles) and biologic responses such as modulation of pain signaling, breakdown of calcium deposits, disruption of scar tissue, transient inflammation, and stimulation of tissue healing and angiogenesis.

Device energy and types: ESWT may be categorized by energy level (e.g., low-energy vs high-energy) and by waveform/focusing (e.g., focused vs radial shock waves); wound healing protocols often use defocused or low-energy acoustical wave patterns.

Indications reviewed: the policy reviews ESWT evidence across multiple conditions, including but not limited to Achilles tendinopathy, rotator cuff/calcific tendinitis, plantar fasciitis, delayed/nonunion fractures, lateral epicondylitis (tennis elbow), hammer toe (no studies identified), tenosynovitis/tibialis tendonitis (no studies identified), and wounds/diabetic foot ulcers (DFUs).

Condition/Topic	Evidence summary
Achilles tendinopathy	Very low-quality evidence; RCTs and systematic reviews report inconsistent results with small sample sizes and heterogeneity; no adequate prospective clinical studies demonstrating clear effectiveness; insufficient to make strong recommendations.
Calcific rotator cuff tendinopathy	Some RCTs and meta-analyses suggest high-energy ESWT may improve pain, function, and calcification resorption; overall evidence low quality and conflicting; additional standardization and high-quality trials needed.
Plantar fasciitis	Conflicting RCTs and meta-analyses; some trials and reviews show benefit (especially radial or high-intensity and at intermediate follow-up), while others are inconclusive; evidence inconsistent and variable by protocol.
Delayed/nonunion fractures	Case series and some studies report union rates ranging ~65%–100%; systematic reviews note limited, heterogeneous evidence and lack of high-quality RCTs; effectiveness remains unproven pending further trials.
Lateral epicondylitis	Conflicting and inconsistent RCT evidence and meta-analyses: some trials report short- or medium-term benefit for pain and grip strength while other sham-controlled trials show no superiority; heterogeneity of devices and protocols limits conclusions.
Refractory Greater Trochanteric Pain Syndrome (GTPS)	Systematic reviews and RCTs show inconsistent results; some trials report benefit but overall evidence is inconclusive and additional robust RCTs are needed.
Diabetic foot ulcers / wounds	Systematic reviews and RCTs (including dermaPACE trials) suggest ESWT may shorten time to healing and increase healing rates for DFUs; evidence described as promising but low-to-moderate certainty; further high-quality studies required.

Definitions

ESWT — Extracorporeal shock wave therapy: Therapeutic delivery of acoustic shock waves (low- or high-energy; focused or radial) to body tissues proposed to produce mechanical and biologic effects (pain modulation, calcification breakdown, inflammatory stimulation, tissue healing).

ESWL — Extracorporeal shock wave lithotripsy: Shock wave treatment used for stone fragmentation (kidney, gallbladder, pancreatic, or salivary stones); this policy does not address ESWL.

Revision History

12/01/2024materialLatest

Applicable CPT code 0864T added to the policy; supporting information updated in Clinical Evidence and References sections (Summary of Changes 12/01/2024).

06/01/2025non-material

Related policy reference to Lithotripsy for Salivary Stones removed (retired Jun 1, 2025).