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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

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.

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.

Criteria

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:

  • 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.

Scientific evidence does not convincingly demonstrate the efficacy of ESWT for musculoskeletal conditions.

Procedure Codes

0101T0102T2889020999

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