Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:

Effective Date: 08/21/2003

Title: Extracorporeal Shock Wave Therapy (Orthotripsy)

Revision Date: 01/01/2019

Document: BI003:00

CPT Code(s): 0101T-0102T, 0512T, 0513T, 28890, 28899

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Extracorporeal Shock Wave Therapy (ESWT) is covered for chronic calcific tendinitis of the shoulder. ESWT is considered experimental/investigational (and not covered) for all other musculoskeletal conditions or for integumentary wound healing.

Medical Statement

The only musculoskeletal condition for which there is convincing evidence of efficacy is chronic calcific tendinitis of the shoulder:

· Duration of chronic calcific tendinitis must be at least 6 months

· Calcium deposit must be > 1 cm

· Conservative measures (rest, ice, NSAIDs, PT) have failed

ESWT is considered experimental/investigational for all other musculoskeletal conditions and integumentary wound healing is not a covered service.

Note: Extracorporeal Shock Wave Lithotripsy, a therapy for kidney stones, is covered.

Codes Used In This BI:

ACTIVE
0101T	Extracorporeal Shock Wave Therapy, musculoskeletal system, NOS, high energy
0102T	Extracorporeal Shock Wave Therapy, lateral humeral condyle, high energy
0512T	ESW INTEGUMENTARY WOUND HEALING INITIAL WOUND (1/1/2019)
0513T	ESW INTEGUMENTARY WOUND HEALING EA ADDL WOUND (1/1/2019)
28890	Extracorporeal Shock Wave Therapy, plantar fascia, high energy
28899	Unlisted procedure, foot or toes
DELETED
0299T	Extracorporeal Shock Wave Therapy for integumentary wound healing, high energy, incl topical application & dressing care; initial wound (deleted 1/1/18)
0300T	each addt’l wound (deleted 1/1/18)

Reference

High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: a systematic review. RR Bannuru, NE Flavin, E Vaysbrot, W Harvey and T McAlindon. Ann Internal Med. 2014:160:542-549

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.