Medical Policy
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)
Limits
Intentially left empty
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.