Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-157
Topic: Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Effective Date: January 1, 2006
Issued Date: January 2, 2006
Date Last Reviewed: 01/2006

General Policy Guidelines

Indications and Limitations of Coverage

Plantar Fasciitis (Procedure Code 28890)

Scientific evidence does not convincingly demonstrate the efficacy of ESWT when used to treat plantar fasciitis (728.71); therefore, this treatment is considered experimental/investigational.  A participating, preferred, or network provider can bill the patient for the denied service.

Lateral Epicondylitis, (Procedure Codes 0019T, 0102T)

Scientific evidence does not convincingly demonstrate the efficacy of ESWT therapy when used to treat lateral epicondylitis (726.32); therefore, this treatment is considered experimental/investigational. A participating, preferred, or network provider can bill the member for services that were denied as being investigational.

Other Musculoskeletal Conditions (Procedure Codes 0019T, 0101T)

Services provided for other musculoskeletal conditions do not have FDA approval; and, as such, are not eligible for reimbursement.

These denied services are considered experimental/investigational. A participating, preferred, or network provider can bill the member for the denied service.

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. The procedure can be successfully performed in a physician’s office or an outpatient facility. Extracorporeal shock wave treatments can be used for the following conditions:

Plantar Fasciitis (Procedure Code 28890)

Plantar fasciitis is a common condition causing pain on the plantar surface of the heel. This condition occurs frequently in runners. In addition to walking and running on hard surfaces, stress, obesity and the normal aging process appear to contribute to the development of this condition.

The standard treatment for plantar fasciitis includes resting the heel surface (no weight bearing), foot massages, stretching exercises, night splints, orthotics, anti-inflammatory drugs, and local steroid injections. In a small percentage of patients, conservative treatment is not successful. For this group of patients, the next option is usually invasive surgery, plantar fasciotomy.

Lateral Epicondylitis, (Procedure Codes 0019T, 0102T)

Extracorporeal shock wave therapy has also been used to treat lateral epicondylitis (tennis elbow) that has not responded to conventional treatment. Conventional treatment consists of local steroid injections, physical/occupational therapy and non-steroidal anti-inflammatories.


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.

Procedure Codes

288900019T0101T0102T  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Extracorporeal shock wave therapy for plantar fasciitis (728.71) and lateral epicondylitis (726.32) is eligible when determined medically necessary based on the patient’s condition.

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/2002, Coverage approved for extracorporeal shock wave therapy for plantar fasciitis

08/2004, Extracorporeal shock wave therapy for plantar fasciitis not covered

06/2005, High-energy extracorporeal shock wave therapy not covered

References

Application of Shock Waves in Medicine, Clinical Orthopaedics and Related Research, Vol. 387, 6/2001

The Use of Extracorporeal Shock Wave Therapy for Chronic Proximal Plantar Fasciitis, Clinical Orthopedics, Vol. 387, 6/2001

Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis, JAMA, Vol. 288, 09/2002

Extracorporeal Shock Wave Therapy in the Treatment of Lateral Epicondylitis, The Journal of Bone and Joint Disease, Vol. 84-A, 11/2002

Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes, The American Journal of Sports Medicine, Vol. 31, 2003

Extra Corporeal Shock Wave Therapy for Plantar Fasciitis: Randomized Controlled Multicentre Trial, British Medical Journal, Vol. 327, 07/2003

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Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.