ModifiedUnitedHealthcarePolicy CS041OH.D

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

UnitedHealthcare Community Plan medical policy governing use of extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications for members in Ohio; establishes coverage stance and references supporting evidence and applicable codes.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS041OH.D

Change TypeTitle revisionInterQual referral removedreferences updated

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionFor members 18 and older, consult InterQual criteria when considering high‑energy ESWT for plantar fasciitis and submit prior authorization with evidence of prior conservative therapy and device/treatment details.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Ohio Only)'

Instruction to refer to InterQual® CP: Procedures, Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT), high energy, for plantar fasciitis

Updated Clinical Evidence and References sections to reflect the most current information

Ohio-onlystate applicability

Members 18+ and <18age groups

Not medically necessarycoverage stance

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6 codesprocedure codes listed

10 RCTsDFU RCTs (Wu et al. 2024)

Coverage Criteria and Evidence Summaries

General Not Medically Necessary with InterQual reference for plantar fasciitis

Covered when ALL of the following are met:

Members 18 Years of Age and Older — see InterQual referenced criteria for plantar fasciitis

Plantar Fasciitis (Chronic)

Clinical evidence summary:

ESWT may be considered for chronic PF only when InterQual criteria are fully met and prior conservative therapies documented

Delayed/Nonunion Fractures

Clinical evidence summary:

InterQual criteria do not establish ESWT as medically necessary for fracture nonunion

Erectile Dysfunction

Clinical evidence summary:

InterQual does not currently support ESWT for ED as standard medical necessity

Lateral Epicondylitis

Clinical evidence summary:

InterQual criteria do not establish routine medical necessity for LE; consider investigational stance for most cases

Hammer Toe

Coverage stance:

Requests for ESWT for hammer toe will be denied; consider standard surgical/orthotic management

Lateral Epicondylitis — evidence overview

Evidence overview:

Evidence does not support broad coverage for LE; consideration may be limited to approved protocols within clinical trials

GTPS — evidence overview

Evidence overview:

Further high-quality RCTs needed before routine coverage is supported

Foot/ankle tendon conditions — no evidence

Evidence overview:

No evidence supports routine use for these tendon conditions

Wounds/DFUs — promising but further research needed

Evidence overview:

Considered investigational for non-DFU wound types; DFU use may be considered on case-by-case basis consistent with device clearance and demonstrated protocol alignment.

Providers should use applicable urology or gastroenterology lithotripsy policies for ESWL indications.

Providers should pursue standard surgical or orthotic management options and document attempts before any exception requests.

Authorization requests for these indications will be denied unless new high-quality evidence is provided or the request is part of an approved clinical trial.

Providers requesting dermaPACE for non-DFU wounds should expect denial; DFU requests require documentation of prior standard wound care and device-specific protocol.

Providers should follow prior authorization and documentation requirements described in the callouts below. State-specific requirements (see Ohio Administrative Code evaluation) and contract-level conflicts must be considered when submitting requests.

Prior Authorization

Provider action: Prior authorization guidance and coding/documentation requirements

Provider action: Prior authorization is required for any ESWT claim for musculoskeletal/soft tissue indications. Requests must include clinical indication, prior conservative treatments, device brand/model, energy settings (EFD), number of shocks per session, number and frequency of sessions, and relevant imaging or consultation notes. For plantar fasciitis, authorization will be adjudicated against the InterQual criteria.

Require prior authorization with device and treatment details
List of procedure codes (non-exhaustive): CPT 0101T (ESWT, high-energy, plantar fasciitis — where applicable), CPT 0122T, HCPCS G0490 (if applicable), ICD-10 diagnosis codes should reflect the specific condition (e.g., M72.2 plantar fasciitis)
Prior authorization guidance: include InterQual decision output when available

Provider Requirements, Prior Authorization, and Documentation

Note

InterQual referenced; procedure codes listed

For members 18 years and older, InterQual® CP: Procedures, Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT), high energy, is referenced for medical necessity determinations. Applicable procedure codes listed in the policy include 0101T, 0102T, 0512T, 0513T, 0864T, and 28890 for reference.

Procedure codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890

Prior Authorization

Submit indication-specific evidence with PA

Prior authorization should include indication-specific evidence and clinical rationale, since guideline and evidence summaries note ESWT has mixed evidence across indications and is considered safe and effective by some organizations for chronic plantar fasciitis but conflicting for others.

Prior Authorization

PA must include device and treatment details

Require prior authorization documentation of prior conservative therapy and specification of the proposed ESWT device and treatment protocol (device/type, energy flux density, number and frequency of sessions) because outcomes vary by device and protocol.

Procedure and Diagnosis Codes

Applicable procedure 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, 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.

Background and Definitions

Extracorporeal shock wave therapy (ESWT) devices deliver focused or radial acoustic shock waves to target musculoskeletal and soft tissues. Proposed mechanisms include mechanical stimulation, cavitation, modulation of pain signaling, and promotion of tissue healing and angiogenesis. ESWT is available in focused and radial modalities and in varying energy levels; devices for these indications are associated with FDA product code NBN (Class III, PMA) and procedure codes listed in the policy.

inv-38: ESWT definition

DefinitionExtracorporeal shock wave therapy (ESWT) — application of acoustic shock waves (low- or high-energy, focused or radial) to musculoskeletal or soft tissues; devices are similar to lithotripters but use lower energy for orthopedic indications.

Mechanism (proposed)Shock waves may produce mechanical effects (positive pressure, cavitation) that reduce pain signal transmission, disrupt calcifications, break down scar tissue, cause transient inflammation, and stimulate tissue healing.

Energy & focus typesESWT may be delivered as low- or high-energy pulses and can be focused or defocused/radial; low-energy defocused ESWT is often used for wound healing.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS041OH.D

Change TypeTitle revisionInterQual referral removedreferences updated

Effective DateJan 1, 2026

Next Review DateN/A

SourceLink

On This Page

Document prior conservative treatments and responses
Specify device type (focused vs radial)
Provide energy parameters, number of sessions, and treatment frequency

Note

Follow InterQual® and plan criteria

UnitedHealthcare uses InterQual® for primary medical/surgical criteria; when InterQual® has applicable criteria (e.g., high-energy ESWT for plantar fasciitis) those criteria should be consulted for medical necessity determinations.

Step Therapy

InterQual implies step requirements

InterQual-based pathways imply prerequisite conservative care before considering high-energy ESWT for plantar fasciitis; follow the referenced InterQual criteria for specific step requirements.

Step Therapy

Document prior conservative therapy before ESWT (general)

Many randomized trials required prior conservative management (for example, home exercise, orthotics, or at least one month of conservative care and sometimes a washout period after injections) before enrolling patients for ESWT.

Document duration and type of conservative care (e.g., home exercise, orthotics)
If prior injections, document time since last injection (some trials required >2 months)

Step Therapy

Conservative therapy required for GTPS and LE prior to ESWT

For Greater Trochanteric Pain Syndrome (GTPS) and lateral epicondylitis (LE), first-line management in the literature is conservative care such as exercise and education; ESWT is generally evaluated after failed conservative measures.

Document trial of exercise and education
Document other conservative modalities tried and response

Documentation Required

Coding and documentation note

Listing of procedure and diagnosis codes in this policy is for reference only; inclusion does not guarantee coverage or payment and documentation must support medical necessity per policy and applicable laws.

Documentation Required

Suggested supporting clinical documentation (outcomes, follow-up)

Support prior authorization with clinical outcome measures and follow-up data used in trials (e.g., VAS pain scores, patient-reported functional scales like PRTEE or Roles and Maudsley, plantar fascia thickness, and documented follow-up intervals at 3–6 months).

Include baseline and follow-up VAS or validated functional scores
Report objective measures when available (e.g., plantar fascia thickness)
Provide follow-up timing and outcomes (e.g., 3 and 6 months)

Documentation Required

Suggested supporting documentation (diagnosis, duration, prior therapies, ESWT parameters)

Clinical documentation for PA should include diagnosis, symptom duration, prior conservative treatments and responses, and targeted ESWT parameters (device/type, energy flux density, number and frequency of sessions) consistent with trial reporting.

Diagnosis and symptom duration
Details of prior conservative therapies and response
Exact ESWT parameters proposed (device type, EFD, sessions)

Note

Reference federal/state/contract requirements for coverage

When determining coverage, reference federal, state (Ohio Administrative Code), or contractual benefit requirements; those requirements govern and may supersede this policy in the event of conflict.

Denial Risk

Ohio Administrative Code evaluation for requests

Requests for services listed as unproven or subject to limits will be evaluated per Ohio Administrative Code 5160-101; Ohio-only policy applicability may lead to denial if state medical necessity standards are not met.

Denial Risk

Insufficient evidence to support ESWT for delayed/nonunion fractures

Evidence is inconclusive for use of ESWT to promote healing of delayed or nonunion fractures; absence of high-quality RCTs and heterogeneous study results may lead to denial for fracture healing indications.

Denial Risk

LE trial evidence may not support coverage

Randomized sham-controlled trials for lateral epicondylitis have shown no consistent benefit of radial ESWT over sham at short-term follow-up, and mixed trial results may support denial when ESWT is requested for LE.

Denial Risk

Risk of state/contract conflict governing coverage

Coverage decisions must follow federal, state (OAC), or contractual benefit requirements; if plan terms conflict with this policy, the applicable federal/state/contractual requirements govern and may affect coverage.

inv-39: Energy classification (low vs high)

Low-energyLower-energy, defocused or soft focused acoustic wave patterns typically used for wound healing; orthopedic shock waves have about one-tenth the energy of lithotripsy used for stones.

High-energyHigher-energy focused shock waves used in some orthopedic applications (e.g., high-energy plantar fascia protocols); numerical thresholds are not standardized in this policy.

Policy noteThe policy distinguishes low- versus high-energy ESWT by clinical use (wounds vs some orthopedic indications) but does not define a specific numeric energy cutoff.

inv-40: Chronic plantar fasciitis definition

Core definitionChronic plantar fasciitis: plantar heel pain persisting despite conservative therapy, often studied after at least one month of conservative care; trials include subacute and chronic presentations.

Evidence summaryRCTs and meta-analyses show conflicting results; some analyses found benefits of ESWT over corticosteroid injections at 3–6 months but not consistently at one year.

Guideline statementACFAS (2017) states 'Extracorporeal shockwave therapy (ESWT) is safe and effective in the treatment of plantar fasciitis' and notes ~70% of chronic/subacute patients had meaningful improvement at 12 weeks.

inv-41: Delayed/nonunion fracture definition

DefinitionDelayed or nonunion fracture: fractures that fail to heal within expected time frames (delayed union or nonunion) requiring interventions to achieve union.

Evidence characteristicsSystematic reviews report heterogeneous studies with varied energy settings, treatment counts, and endpoints; reported union rates after ESWT vary across series (e.g., delayed-union ~86%, nonunion ~73% in Willems et al. 2019), but high-quality RCTs are lacking.

ConclusionThe effectiveness of ESWT for delayed/nonunion fractures remains inconclusive and further high-quality, standardized RCTs are needed.

inv-42: Radial ESWT vs Focused ESWT distinction

Radial ESWTRadial (defocused) ESWT delivers pressure waves that disperse radially from the applicator surface; often evaluated in trials for lateral epicondylitis with mixed results.

Focused ESWT (F-ESWT)Focused ESWT concentrates acoustic energy at a target tissue depth (energy flux density reported in trials, e.g., Ramon et al. used EFD 0.20 mJ/mm2 vs 0.01 mJ/mm2); used in tendinopathies and some positive trials for GTPS.

Clinical implicationDifferent device types and energy delivery (radial vs focused, low vs high energy) are sources of heterogeneity and may affect outcomes; prior authorization should specify device/type and parameters.

inv-43: ESWT (duplicate key) summary

Scope statementESWT encompasses low- and high-energy, focused and radial (defocused) acoustic shock-wave therapies applied to musculoskeletal and soft-tissue conditions and wounds.

Clinical uses notedClinical literature evaluates ESWT for plantar fasciitis, tendinopathies (lateral epicondylitis, GTPS), delayed/nonunion fractures, diabetic foot ulcers, and erectile dysfunction among others.

Policy stanceUnitedHealthcare policy considers ESWT (low, high, or radial) unproven and not medically necessary for musculoskeletal or soft tissue indications except that InterQual criteria may be consulted for consideration of high-energy ESWT for plantar fasciitis in adults.

inv-44: FDA classification

FDA product codeProduct code NBN — generator, shock-wave, for pain relief.

Device classESWT products have been classified by the FDA as Class III devices subject to the premarket approval (PMA) program.

NoteFDA classification information is provided for informational purposes only and is not by itself a basis for coverage decisions.