All Policies and Precertification
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Extracorporeal shock wave therapy (ESWT) is designed to provide a non-surgical, non-invasive alternative for treating musculoskeletal conditions by bombarding the surface of the treatment area with acoustic shock waves.
Coverage is subject to the specific terms of the member’s benefit plan.
ESWT, high- or low-dose protocol or radial ECWT is considered experimental/investigational as a treatment for musculoskeletal conditions, including but not limited to:
ESWT for all other indications 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.
Internal Medical Policy Committee 11-14-2019 Removed Deleted Code (0019T)
Internal Medical Policy Committee 11-19-2020 Annual Review
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.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Scientific evidence does not convincingly demonstrate the efficacy of ESWT for musculoskeletal conditions.
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