Extracorporeal shock wave therapy (ECSWT) has been used for years to treat kidney stones. ECSWT has been used in other countries to treat certain localized painful musculoskeletal conditions, such as plantar fasciitis and lateral epicondylitis. This is a non-invasive treatment using the acoustic force of a shock wave. The exact scientific mechanism of action is unknown, but it is thought to disrupt fibrous tissue with subsequent promotion of revascularization and healing of tissue. Shock waves of varying energies have been used – this policy is inclusive of both high and low energy treatment protocols.

ECSWT is considered medically necessary for the following conditions:

• When services for ECSWT are done with FDA approved devices, and these approved devices are used only for their specific FDA approved indications.
• At present, only plantar fasciitis and lateral epicondylitis are covered indications for use of this modality. All other conditions are considered investigational and not covered,
• ECSWT may be medically indicated for treatment of plantar fasciitis or lateral epicondylitis when all of the following criteria are met:
  • The member has been symptomatic for at least six (6) months,
  • There has been a lack of response for at least the last two months to conservative measures, including –
    • Rest
    • Physical therapy
    • Anti-inflammatory medications
    • Local corticosteroid injections
    • Heel orthotics or forearm sleeve (as applicable)
  • The member would otherwise be considered a candidate for surgical treatment.

Reasons for Noncoverage

Services provided for conditions not outlined on this policy will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Utilization Guidelines
For treatment plans that are based on a treatment protocol using a single application of shock waves (generally referred to as high energy), for any anatomical site:

• Only one (1) treatment will be covered per site in any six (6) month period.
• No more than two (2) treatments will be covered for any site in a calendar year.
• Repeat treatments may be medically necessary and may be covered if the following conditions are met:
  • Previous treatment resulted in significant improvement in symptoms and function;
  • The criteria for initial treatment had been met;
  • For repeat treatment, documentation must be maintained in the medical record to support medical necessity.
• Until such time as RVUs and a CPT code are established for this procedure, any use of ultrasound will be included in the fee for the procedure.
• Anesthesia, such as local or regional blocks, when performed by the operating physician, will not be reimbursed separately. If medical necessity for administration of anesthesia by an anesthesiologist is present, this may be covered separately if sufficient documentation is present to justify medical necessity.

For treatment plans that are based on a treatment protocol using multiple applications of the shock wave modality (usually referred to as low energy), for any anatomical site:

• No more than three (3) treatments will be covered for any single anatomic site during a six month period
• No more than six (6) treatments will be covered per year per site
• Repeat treatments may be medically necessary and covered if the following conditions are met:
  • Previous treatment resulted in significant improvement in symptoms and function
  • The criteria for initial treatment had been met
  • For repeat treatment, documentation must be maintained in the medical record to support medical necessity.
• Until such time as RVUs and a CPT code are established for this procedure, any use of ultrasound will be included in the fee for the procedure.
• Anesthesia, such as local or regional blocks, when performed by the operating physician, will not be reimbursed separately. Because anesthesia is rarely required for this application, anesthesia performed by any provider other than the operating physician will be considered only on a case by case basis for medical necessity.
• If during a protocol based on multiple applications (low energy) the therapeutic goal is reached after the first or second treatment, subsequent treatments would not be medically necessary and not separately payable.

Documentation Requirements

Documentation supporting the medical necessity and criteria specified above should be legible, maintained in the patient’s medical record, and must be made available upon request.

Appropriate diagnosis codes must be on all claims, and must be coded to the highest level of specificity.

NOTE:

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.

0101T is a non-covered service, and therefore will not pay. Please note that only plantar fasciitis and lateral epicondylitis are covered for for this procedure. Treatments to all other body areas will be denied as not medically necessary.

NOTE:

Please use 0019T, Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy, to denote treatment of plantar fasciitis or lateral epicondylitis with low energy modalities.

Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be reasonable and necessary.

Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits payment for any claim which lacks the necessary information to process the claim.

The use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.

Covered Diagnosis Codes

For codes 0019T, 0102T, and 28890.