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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.
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
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:
Procedure Codes
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
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.
0512T
0513T
Not Applicable
Internal Medical Policy Committee 11-14-2019
Internal Medical Policy Committee 11-19-2020 Annual Review.
Internal Medical Policy Committee 11-23-2021 Revision
Internal Medical Policy Committee 7-21-2-2022 Revision
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
Internal Medical Policy Committee 1-14-2025 Annual Review-no changes in criteria
Internal Medical Policy Committee - Annual Review-no changes in criteria
References (PDF)
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.
Internal Medical Policy Committee 11-23-2021 Revision;
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