ModifiedUnitedHealthcarePolicy CS041KY.11

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

This Kentucky-only UnitedHealthcare medical policy governs coverage and medical necessity for extracorporeal shock wave therapy (ESWT) for musculoskeletal conditions and soft tissue indications, specifying age-based stances and referencing InterQual criteria for plantar fasciitis.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS041KY.11

Change TypeTitle and coverage rationale revisedInterQual instruction removed

Effective DateApril 1, 2026

Next Review DateN/A

Key ActionObtain applicable prior authorization and document adherence to InterQual criteria for adult plantar fasciitis when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions' to include Soft Tissue Indications and wounds for Kentucky.

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

Clinical Evidence and References sections were updated to reflect the most current information.

Kentucky-onlystate applicability

Members 18+Adults reference

UnprovenPolicy stance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Evidence Summaries

Documentation Required

Provider actions and documentation requirements

Document baseline clinical status and objective outcomes (e.g., pain scores, functional measures, imaging findings) and the duration of symptoms.
Document prior conservative care attempted, including specific therapies, duration, and response (exercise/education, orthoses, medications, physical therapy, injections where applicable).
For indications with guideline-recommended conservative management (e.g., GTPS), ensure exercise and education have been trialed and documented before considering ESWT.
Recognize there are no identified clinical studies for some conditions (e.g., hammer toe, tenosynovitis of foot/ankle, tibialis tendonitis); ESWT for these lacks clinical evidence and is not supported by trials.

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior authorization and affected codes

Prior authorization is implied for ESWT services referenced by the listed procedure codes; for plantar fasciitis in adults, coverage requires meeting InterQual criteria.

Affected procedure codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890

Prior Authorization

Prior authorization recommended for ESWT

Given mixed and condition‑specific evidence (supportive for chronic plantar fasciitis but conflicting for other indications), prior authorization is recommended to confirm indication and documentation.

Prior Authorization

Prior authorization for indication and conservative therapy

Prior authorization may be required to demonstrate the specific indication and prior conservative therapy (e.g., for GTPS or DFU) given variable evidence and device/dose heterogeneity.

Prior Authorization

Prior authorization guidance: InterQual and UHC use

Utilization determinations may use InterQual® and UnitedHealthcare policies; if InterQual® criteria apply they are used for medical/surgical criteria — providers should obtain applicable prior authorization per plan rules.

Documentation Required

Consider conservative therapy in documentation

Evidence reviews compare ESWT to conservative treatments (for example, corticosteroid injections and standard care in plantar fasciitis); document prior conservative care when requesting coverage.

Step Therapy

Stepwise conservative therapy usually expected before ESWT

For plantar fasciitis, studies often compared ESWT to standard care and injections; failure of stepwise conservative therapies (exercise, orthotics, injections when appropriate) is generally expected before ESWT is considered.

Step Therapy

Exercise/education first‑line for gluteal tendinopathy

Guidance for gluteal tendinopathy/GTPS emphasizes exercise and education as core first‑line approaches and suggests other treatments (including ESWT) be considered only after these measures.

Step Therapy

Follow plan‑specific UM/step therapy tools

No explicit step therapy requirements are specified in this policy; follow plan‑specific utilization management tools (e.g., InterQual®) where applicable.

Documentation Required

Document InterQual plantar fasciitis criteria

For adults with plantar fasciitis, medical necessity criteria reference InterQual® Procedures, Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT); providers should document adherence to InterQual criteria when requesting coverage.

Documentation Required

Document clinical outcomes and prior conservative care

Document prior conservative care duration and outcome measures (e.g., pain and functional scores) and rationale for ESWT; studies commonly report outcomes at ~12 weeks.

Documentation Required

DFU documentation: ulcer details, SOC, and HbA1c

For diabetic foot ulcers, document ulcer characteristics, prior standard of care measures, HbA1c/glycemic control, ulcer assessment timing, and the specific ESWT dosing/energy parameters used.

Note

Check benefit plan terms before applying policy

Before applying this policy, check federal, state, or contractual benefit plan coverage terms; in the event of conflict, the federal/state/contractual requirements govern and may affect coverage.

Denial Risk

Denial risk: refractory GTPS (insufficient evidence)

There is insufficient quality evidence to conclude ESWT is effective for refractory GTPS; requests for ESWT for GTPS may be denied due to lack of established efficacy.

Denial Risk

Denial risk: tenosynovitis/tibialis tendonitis — no studies

A detailed literature search identified no clinical studies evaluating ESWT for tenosynovitis of the foot/ankle or for tibialis tendonitis; absence of studies may lead to denial for these indications.

Denial Risk

Benefit plan compliance required

Coverage decisions must reference federal, state, or contractual benefit plan requirements; failure to follow those terms may result in noncoverage or denial.

Procedure and Billing Codes (Reference)

Applicable procedure codes (reference only)CPT

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.

Documentation Required

Cross‑reference InterQual for plantar fasciitis and codes

InterQual® Procedures, Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT) is the referenced clinical criteria for adult plantar fasciitis and should be used when requesting coverage for plantar‑fascia–related ESWT codes (e.g., CPT 28890).

Affected code example: 28890 (plantar fascia, high‑energy ESWT)

Background and Definitions

Extracorporeal shock wave therapy (ESWT) delivers focused or radial acoustic shock waves of varying energy levels. Proposed mechanisms include mechanical disruption of calcifications, modulation of pain signaling, and stimulation of biological responses that enhance perfusion and angiogenesis to promote tissue healing. Devices and protocols differ by indication: some orthopedic applications use higher energy flux densities (sometimes requiring anesthesia and image guidance), while low‑intensity or defocused waveforms are described for wound healing. The biological mechanisms are plausible but not fully established, and clinical benefit appears to vary by indication, device, energy dose, and treatment regimen.

Low-energy ESWT

DefinitionLow-energy ESWT: defocused or soft-focused acoustical wave pattern used for wound healing; lower energy than lithotripsy and orthopedic high-energy treatments.

Energy characteristicProduces low-energy acoustic shock waves with substantially less energy than lithotripsy (approximately one-tenth of lithotripter energy).

Typical usePrimarily used for wound healing and soft-tissue indications where a defocused wave pattern is desired.

Mechanism noteMay stimulate tissue healing via mechanical effects on cells, bubble implosion, transient inflammation and angiogenesis (mechanism not fully established).

Policy Revision History

2026-04-01RevisionLatest

Title updated and coverage rationale revised; instruction to refer to InterQual® for plantar fasciitis ESWT was removed and clinical evidence/references were refreshed (previous version CS041KY.10 archived).