Coverage Policies

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.

1)    Plantar fasciitis treatment by shock wave therapy is not covered.

2)    Plantar fasciitis treatment by radiofrequency ablation treatment is considered experimental/investigational and not covered.

3)    Endoscopic plantar fasciotomy is a covered service.

1.    QualChoice considers endoscopic plantar fasciotomy as an alternative to conventional open plantar fasciotomy medically necessary in members with intractable plantar fasciitis or heel spur syndrome who have failed a 6-month trial of conservative therapy.

2.    QualChoice considers extracorporeal shock-wave therapy (ESWT) with the OssaTron (HealthTronics, Marietta, GA), the Dornier Epos Ultra (Dornier Medical Systems, Kennesaw, GA), the Sonocur (Siemens Medical Solutions Inc., Iselin, NJ), the Orbasone Pain Relief System (Orthometrix, Inc., White Plains, NY), the OrthospecTM Extracorporeal Shock Wave Therapy (Medispec, Ltd., Germantown, MD), or any other ESWT devices experimental and investigational for plantar fasciitis. Search for BI "Extracorporeal Shock Wave Therapy (Orthotripsy)"

3.    QualChoice considers radiofrequency lesioning, radiotherapy, marrow stimulation techniques (micro fracture, drilling), or cryosurgery (cryotherapy) experimental and investigational for members with plantar fasciitis.  There is a lack of published literature documenting the safety and efficacy of these techniques in the treatment of plantar fasciitis.  

Codes Used In This BI:

28890 High Energy Eswt Plantar Fascia (deleted 1-1-15)
0019T Extracorp Shockwave Tx Ms NOS (deleted 1-1-15)
0101T Extracorp Shockwave Tx Hi Enrg
0102T Extracorp Shockwave Tx Anesth
29893 Endoscopic plantar fasciotomy
77401 Rad trmt delivery, super/ortho voltage, per day
77402 Rad trmt del, =>1 MeV; simple
77407 Rad trmt del, =>1 MeV; intermed
77412 Rad trmt del, =>1 MeV; complex
77417 Therapeutic rad port film(s)
77403 Simple; 6-10 MeV (deleted 1-1-15)
77404 Simple; 11-19 MeV (deleted 1-1-15)
77406 Simple; 20 MeV or grtr (deleted 1-1-15)
77408 Itrmed; 6-10 MeV (deleted 1-1-15)
77409 Itrmed; 11-19 MeV (deleted 1-1-15)
77411 Itrmed; 20 MeV or grtr (deleted 1-1-15)
77413 Complex; 6-10 MeV (deleted 1-1-15)
77414 Complex; 11-19 MeV (deleted 1-1-15)
77416 Complex; 20 MeV or grtr (deleted 1-1-15)
77418 IMRT Delivery (deleted 1-1-15)
77421 Stereoscopic Imaging Guide (deleted 1-1-15)
 

Plantar fasciitis is defined as the traction degeneration of the plantar fascia at its origin on the heel.  Plantar fasciitis is the most common cause of chronic heel pain.  It is usually caused by bone spurs or inflammation of the foot`s connective tissue and the condition may be resistant to conservative treatment.  Conservative treatments for plantar fasciitis include rest, physical therapy, heel cushions, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, taping, foot orthotics, shoe modifications, night splinting, and casting.

Surgical intervention may be indicated for patients who fail conservative treatment.  Well-designed placebo- or sham-controlled clinical trials for plantar fasciitis are especially important because: 1) most cases of plantar fascial pain resolve spontaneously over time; and 2) pain is a symptom that is especially susceptible to placebo effects.

Radiofrequency lesioning is used to ablate pain pathways and is generally employed for intractable pain that has not responded to conservative measures.  Radiofrequency lesioning is not an established procedure for the treatment of plantar fasciitis.

Most recently, extracorporeal shock wave therapy (ESWT) has been used to treat plantar fasciitis.  ESWT is thought to relieve pain by disrupting scar tissue, causing microscopic damage to that tissue.  This induces new blood vessel formation into the injured area and facilitates the healing process.

The Dornier EPOS Ultra is an ESWT system that uses electromagnetic energy to generate a shock wave, which travels through a water-filled coupling cushion mounted to a therapy head. The therapy head has an acoustic lens to focus the shock wave treatment on the target tissue.  The EPOS Ultra also has an ultrasound imaging system that is used to observe and monitor the shock wave treatment. Typically, 3800 shock waves are delivered over 20 minutes.

In support of their pre-market approval application (PMA), a randomized, double-blind, sham-treatment-controlled study was conducted involving 150 adult patients with chronic plantar fasciitis enrolled at 6 clinical centers.  Patients had at least moderate pain (Visual Analog Score (VAS) greater than 5) for at least six months and a history of prior conservative therapy (including NSAIDs and two other conservative therapies).  After being randomized to active or sham treatment groups, patients underwent a single ESWT session, and were followed for 12 months.  After 3 months, patients who received sham treatment were offered active unmasked treatment. To maintain physician blinding during the first 3 months of the study, the treatment was administered by a physician who did not perform the follow-up evaluations.

Although there was a modest, statistically significant difference in improvement in VAS pain scores from baseline (the primary study endpoint) between active and sham treatment groups at three months, this was not accompanied by a significant improvement of function.  In the active group, the pain score decreased by an average of 56.5% by the end of three months; in the sham group, the average pain score decreased by 46.6%.  Patients in the active group were more likely (56%) than patients in the sham group (45%) to report an improvement in VAS pain scores of 60% or more from baseline; however, this difference was not statistically significant.

1. Barrett SL, Day SV. Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: Surgical technique - Early clinical results. J Foot Ankle Surg. 1991;30:568-570.  
2. Barrett SL, Day SV. Endoscopic plantar fasciotomy: Two portal endoscopic surgical techniques - Clinical results of 65 procedures. J Foot Ankle Surg. 1993;32:248-256.  
3. Barrett SL, Day SV, Pignetti TT, Robinson LB. Endoscopic plantar fasciotomy: A multi-surgeon prospective analysis of 652 cases. J Foot Ankle Surg. 1995;34(4):400-406.  
4. Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1995;34(30):305-311. 
5. Stone PA, McClure LP. Retrospective review of endoscopic plantar fasciotomy. 1994 through 1997. J Am Podiatr Med Assoc. 1999;89(2):89-93.  
6. Brekke MK, Green DR. Retrospective analysis of minimal-incision, endoscopic, and open procedures for heel spur syndrome. J Am Podiatr Med Assoc. 1998;88(2):64-72.  
7. Stone PA, Davies JL. Retrospective review of endoscopic plantar fasciotomy--1992 through 1994. J Am Podiatr Med Assoc. 1996;86(9):414-420.  
8. Wander DS. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1996;35(2):183-184.  
9. Landsman A. Endoscopic plantar fasciotomy: A multi-surgeon prospective analysis of 652 cases. J Foot Ankle Surg. 1996;35(1):86.  
10. Barrett SL. Endoscopic plantar fasciotomy. Clin Podiatr Med Surg. 1994;11(3):469-481.  
11. Wander DS. Endoscopic plantar fasciotomy versus traditional heel spur surgery. J Foot Ankle Surg. 1994;33(3):322.  
12. Kinley S, Frascone S, Calderone D, et al. Endoscopic plantar fasciotomy versus traditional heel spur surgery: A prospective study. J Foot Ankle Surg. 1993;32(6):595-603. 
13. Basford JR, Malanga GA, Krause DA, Harmsen WS. A randomized controlled evaluation of low-intensity laser therapy: Plantar fasciitis. Arch Phys Med Rehab. 1998;79(3):249-254.  
14. Seegenschmiedt MH, Keilholz L, and Katalinic A, et al. Heel spur: Radiation therapy for refractory pain - Results with three treatment concepts. Radiology. 1996;200(1):271-276.  
15. Sollitto RJ, Plotkin EL, Klein PG, Mullin P. Early clinical results of the use of radiofrequency lesioning in the treatment of plantar fasciitis. J Foot Ankle Surg. 1997;36(3):215-219; discussion 256.  
16. U.S. Department of Health and Human Services, Food and Drug Administration (FDA), Center for Device Evaluation and Research (CDER). PMA for HealthTronics Ossatron. Orthopedics and Rehabilitation Devices Advisory Committee Transcript. Gaithersburg, MD: FDA; July 20, 2000. Available at: http://www.fda.gov/ohrms/dockets/ac/00/transcripts/3633t1.rtf