Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds

Policy ID: S-157-028

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 12, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Extracorporeal shock wave therapy (ESWT) is designed to provide a non-surgical, non-invasive alternative for treating musculoskeletal conditions and soft tissue wounds by bombarding the surface of the treatment area with acoustic shock waves.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

ESWT, high- or low-dose protocol or radial ESWT as a treatment for musculoskeletal conditions is considered experimental/investigational and therefore, non-covered, because the safety/and or effectiveness of this service cannot be established by the available published peer-reviewed literature, including but not limited to:

Plantar fasciitis; or
Tendinopathies including tendinitis of the shoulder, tendinitis of the elbow (lateral epicondylitis), Achilles tendinitis, and patellar tendinitis; spasticity; stress fractures; delayed union; or
Non-union of fractures; and avascular necrosis of the femoral head.

Procedure Codes

0101T

0102T

0864T

28890

20999

ESWT for the treatment of soft tissue wounds is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

0512T

0513T

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019

Removed Deleted Code (0019T)

Internal Medical Policy Committee 11-19-2020 Annual Review.

Internal Medical Policy Committee 11-23-2021 Revision;

Changed title

Internal Medical Policy Committee 7-21-2-2022 Revision

Updated with clarifying language.

Internal Medical Policy Committee 7-26-2023 Annual Review no changes in criteria

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Added procedure code 0864T

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-157-027

Section: Surgery

Effective Date: July 01, 2018

Revised Date: July 20, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 26, 2023

Archived Date: December 31, 2023

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Plantar fasciitis; or
Tendinopathies including tendinitis of the shoulder, tendinitis of the elbow (lateral epicondylitis), Achilles tendinitis, and patellar tendinitis; spasticity; stress fractures; delayed union; or
Non-union of fractures; and avascular necrosis of the femoral head.

Procedure Codes

0101T

0102T

28890

20999

Procedure Codes

0512T

0513T

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019

Removed Deleted Code (0019T)

Internal Medical Policy Committee 11-19-2020 Annual Review.

Internal Medical Policy Committee 11-23-2021 Revision;

Changed title

Internal Medical Policy Committee 7-21-2-2022 Revision

Updated with clarifying language.

Internal Medical Policy Committee 7-26-2023 Annual Review no changes in criteria

Links

References (PDF)

Disclaimer

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