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Date Printed: October 23, 2017: 02:13 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-24

Original Effective Date: 09/27/01

Reviewed: 08/24/17

Revised: 09/15/17

Subject: Extracorporeal Shock Wave (ESW) for Treatment of Plantar Fasciitis and Other Musculoskeletal Conditions

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Extracorporeal shock wave (ESW/ESWT) treatment is also known as orthotripsy. ESW has been available since the early 1980s for the treatment of renal stones. The mechanism by which ESWT might have an effect on musculoskeletal conditions is not well defined. Chronic musculoskeletal conditions, such as (tendinitis), can be associated with a substantial degree of scarring and calcium deposition. Calcium deposits may restrict motion and encroach on other structures such as nerves and blood vessels, causing pain and decreased function. One hypothesis is that disruption of these calcific deposits by shock waves may loosen adjacent structures and promote resorption of calcium, thereby decreasing pain and improving function.

Currently a number of ESWT devices are approved for marketing by the U.S. Food and Drug Administration (FDA):

• OssaTron® (chronic proximal plantar fasciitis; lateral epicondylitis)

• Epos™ Ultra (plantar fasciitis)

• Sonocur® Basic (chronic lateral epicondylitis)

• Orthospec™ Orthopedic ESWT (chronic proximal plantar fasciitis in patients ≥18 y)

• Orbasone™ Pain Relief System (chronic proximal plantar fasciitis in patients ≥18 y)

• Duolith® SD1 Shock Wave Therapy (chronic proximal plantar fasciitis in patients ≥18 y)

• Dolorclast® (radial ESWT; chronic proximal plantar fasciitis in patients ≥18 y)

There are 2 types of ESWT, focused and radial. Focused ESWT sends medium- to high-energy shockwaves of single pressure pulses lasting microseconds, directed on a specific target using ultrasound or radiographic guidance. Radial ESWT transmits low- to medium-energy shockwaves radially over a larger surface area.

POSITION STATEMENT:

Extracorporeal shock wave therapy (ESWT), using high-dose protocol, low-dose protocol, or radial ESWT is considered experimental or investigational, as a treatment of musculoskeletal conditions, including but not limited to:

There is a lack of scientific evidence to permit conclusions on efficacy and net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

0101T

Extracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy (Investigational)

0102T

Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle (Investigational)

28890

Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia (Investigational)

There are no specific CPT codes for low energy or radial ESWT.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

Achilles tendinitis: Located at the Achilles tendon; symptoms usually present as pain or stiffness 2-6 cm above the posterior calcaneus.

Avascular necrosis (AVN) of the femoral head: A pathologic process that results from interruption of blood supply to the bone. It is also called aseptic necrosis or osteonecrosis.

Delayed union: A fracture that fails to consolidate (unite) within normal limits, less than 9 months (i.e., healing has slowed with no indications that union will fail).

Lateral epicondylitis: Located at the lateral elbow (insertion of wrist extensors); symptoms include tenderness over the lateral epicondyle and proximal wrist extensor muscle mass, pain with resisted wrist extension with elbow in full extension, and/or pain with passive terminal wrist flexion with elbow in full extension.

Nonunion: A fracture site that shows no visibly progressive signs of healing after 3 months or more, as confirmed by serial radiographs (i.e., bone healing has ceased).

Patellar tendinopathy: Located at the proximal tendon at the lower pole of the patella; symptoms include pain over anterior knee and patellar tendon; may progress to tendon calcification and/or tear.

Plantar fasciitis: A common ailment characterized by deep pain in the plantar aspect of the heel, particularly on arising from bed. While the pain may subside with activity, in some patients the pain persists, interrupting activities of daily living.

Shoulder tendinopathy: Located at the rotator cuff muscle tendons, most commonly supraspinatus; symptoms usually present as pain with overhead activity.

Spasticity: A motor disorder characterized by increased velocity-dependent stretch reflexes. It is one characteristic of upper motor neuron dysfunction, which may be due to a variety of pathologies.

Tendonitis, Tendinitis: An inflammation of a tendon.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. AHRQ/National Guideline Clearinghouse. NGC-8320, Shoulder (acute & chronic). Work Loss Data Institute; 2011. Encinitas, CA. Accessed 08/31/11.
  2. Blue Cross Blue Shield Association Medical Policy Reference Manual. 2.01.40 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions (June 2017).
  3. Blue Cross Blue Shield TEC Assessment “Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis”. Volume 19, No. 18, (03/05).
  4. Blue Cross Blue Shield TEC Assessment. “Extracorporeal Shock Wave Treatment for Chronic Tendinitis of the Elbow (Lateral Epicondylitis)”. Volume 19, No. 16, (02/05).
  5. Buchbinder R, Green SE, Youd JM, Assendelft WJJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003524. DOI: 10.1002/14651858.CD003524.pub2.
  6. Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA. 2002 Sep 18; 288(11): 1364-72.
  7. Cacchio A, Giordano L, Colafarina O, Rompe JD, Tavernese E, Ioppolo F, Flamini S, Spacca G, Santilli V. Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions. J Bone Joint Surg Am. 2009;91:25 89-97.
  8. California Technology Assessment Forum (CTAF). Extracorporeal Shock Wave Therapy (ESWT) For Plantar Fasciitis Not Responding to Conservative Therapy. (06/20/07).
  9. Canadian Agency for Drugs and Technologies in Health. Issues in Emerging Technologies. Extracorporeal shock wave treatment for Chronic plantar fasciitis (heel pain). Issue 96. Part 1. January 2007.
  10. Canadian Agency for Drugs and Technologies in Health. Issues in Emerging Technologies. Extracorporeal shock wave treatment for lateral epicondylitis (elbow pain). Issue 96. Part 2. January 2007.
  11. Canadian Agency for Drugs and Technologies in Health. Issues in Emerging Technologies. Extracorporeal shock wave treatment for rotator cuff tendonitis (shoulder pain). Issue 96. Part 3. January 2007.
  12. Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004 Oct-Nov; 32(7): 660-7.
  13. ClinicalTrials.gov NCT00653081. Supervised Exercises Compared with Radial Extracorporal Shock Wave Therapy (rESWT) in Patients with SIS. Verified on January 2007 by Ullevaal University Hospital. Last Updated on April 3, 2008. Accessed 09/01/11.
  14. ClinicalTrials.gov NCT00958620. Shockwave Therapy of Chronic Achilles Tendinopathy. Verified August 12, 2009 by Aalborg Hospital - Aarhus University Hospital, Denmark. Accessed 08/31/11.
  15. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD000416. DOI: 10.1002/14651858. CD000416.
  16. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Extracorporeal Shockwave Therapy for Epicondylitis. Updated 07/17/06.
  17. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Extracorporeal Shockwave Therapy for Shoulder Tendonitis. Updated 07/17/06.
  18. ECRI Institute, Extracorporeal Shock Wave Therapy for the Treatment of Plantar Fasciitis, 11/06. Updated 08/17/07.
  19. ECRI Windows on Medical Technology. Extracorporeal Shockwave Therapy for Epicondylitis, (10/02).
  20. Eslamian F, Shakouri SK, Jahanjoo F, Hajialiloo M, Notghi F. Extra Corporeal Shock Wave Therapy Versus Local Corticosteroid Injection in the Treatment of Chronic Plantar Fasciitis, a Single Blinded Randomized Clinical Trial. Pain medicine (Malden, Mass.). 2016 Sep;17(9):1722.
  21. Florida Medicare Part B Local Coverage Determination. L5780 NCSVCS The List of Medicare Noncovered Services, (08/07/06).
  22. Florida Medicare Part B local Coverage Determination. List of Medicare Noncovered Services. (L5780) 10/20/1997, Revised 07/01/08. Accessed 08/15/08.
  23. Florida Medicare Part B local Coverage Determination. List of Medicare Noncovered Services. (L29288). Revised 08/11/09. Accessed 09/01/11.
  24. First Coast Service Options, Inc. (FCSO). Local Coverage Determination L33777: Noncovered Services (10/01/15).
  25. Hayes Inc. Medical Technology Directory: “Extracorporeal Shock Wave Therapy for Chronic Lateral Epicondylitis of the Elbow.” Lansdale, PA: Hayes, Inc. 08/22/05; update performed 09/02/07.
  26. Hayes Inc. Medical Technology Directory: “Extracorporeal Shock Wave Therapy for Chronic Plantar Fasciitis” Lansdale, PA: Hayes, Inc. 08/22/05; update performed 02/13/08.
  27. Hayes Inc. Medical Technology Directory: “Extracorporeal Shock Wave Therapy for Tendonitis of the Rotator Cuff.” Lansdale, PA: Hayes, Inc. 08/22/05; update performed 09/01/07.
  28. Hayes, Inc., Extracorporeal Shock Wave Therapy for Tendonitis of the Rotator Cuff, 08/06.
  29. Institute for Clinical Systems Improvement (ICSI). Extracorporeal Shock Wave Therapy for Plantar Fasciitis. ICSI Technology Assessment Report # 86. Bloomington, MN: ICSI; November 2004.
  30. InterQual® 2011. CP:Procedures Adult. Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT).
  31. InterQual® 2014 CP: Procedures: Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT).f
  32. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007 Sep 15; 76(6):843-8.
  33. Kvalvaag E, Brox JI, Engebretsen KB, Søberg HL, Bautz-Holter E, Røe C. Is radial Extracorporeal Shock Wave Therapy (rEWST) combined with supervised exercises (SE) more effective than sham rESWT and SE in patients with subacromial shoulder pain? Study protocol for a double-blind randomised, sham-controlled trial. BMC Musculoskelet Disord. 2015 Sep 11;16:248.
  34. Ma YW, Jiang DL, Zhang D, Wang XB, Yu XT. Radial Extracorporeal Shock Wave Therapy in a Person With Advanced Osteonecrosis of the Femoral Head. Am J Phys Med Rehabil. 2016 Sep;95(9):e133-9.
  35. MedicineNet.com. Medical definition: Avascular necrosis of the femoral head. Accessed at http://www.medicinenet.com/.
  36. Pavone V, Cannavò L, Di Stefano A, Testa G, Costarella L, Sessa G. Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series. Biomed Res Int. 2016;2016:7123769.
  37. Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005 Jun; 87(6): 1297-304.
  38. Rodriguez-Merchan EC. The treatment of patellar tendinopathy. J Orthop Traumatol. 2013 Jun;14(2):77-81.
  39. Rompe JD, Cacchio A, Weil Jr. L, Furia JP, Haist J, Reiners V, Schmitz C, Maffulli N. Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy. J Bone Joint Surg Am. 2010;92:2514-22.
  40. Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis. J Orthop Res. 2005 Jul; 23(4): 931-41.
  41. Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs. Medicine. 2017 Apr;96(15).
  42. Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2005 Apr 22; 6: 19.
  43. U. S. Food and Drug Administration (FDA). Notice of Approval #P000048 Dornier Epos™, 01/15/02.
  44. U. S. Food and Drug Administration (FDA). Notice of Approval #P010039 Siemens SONOCUR® Basic System, 07/19/02.
  45. U. S. Food and Drug Administration (FDA). Notice of Approval #P990086 Health Tronics Ossa Tron, 10/12/00.
  46. Van der Worp H, van den Akker-Scheek I, van Schie H, Zwerver J. ESWT for tendinopathy: technology and clinical implications. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1451-8.
  47. Williams H, Jones SA, Lyons C, Wilson C, Ghandour A. Refractory patella tendinopathy with failed conservative treatment-shock wave or arthroscopy? J Orthop Surg (Hong Kong). 2017 Jan;25(1):2309499016684700.
  48. Wu Z, Yao W, Chen S, Li Y. Outcome of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy with and without Haglund's Deformity. Biomed Res Int. 2016;2016:6315846.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/24/17.

GUIDELINE UPDATE INFORMATION:

09/27/01

New Medical Coverage Guideline.

04/25/02

Annual review.

01/01/03

HCPCS coding update.

04/15/03

Reviewed; no changes.

01/01/04

HCPCS coding update. Changed the policy number from 09-E0000-39 to 02-20000-24.

04/15/04

Scheduled review and revision to guideline; consisting of updated references.

07/01/05

3rd quarter HCPCS coding update; consisting of revision of code 0019T and addition of code 0101T and 0102T.

10/15/05

Scheduled review and revision of guideline; consisting of updated references.

01/01/06

Annual HCPCS coding update consisting of the deletion of codes G0279 – G0280 and the addition of code 28890.

10/15/06

Scheduled review and revision of guideline consisting of updated references and maintaining investigational statement.

07/15/07

Annual review; investigational status maintained, guideline reformatted, references updated.

10/15/08

Scheduled review; no change in position statement. Update references.

10/15/09

Scheduled review; no change in position statement. Update description section and references.

10/15/11

Scheduled review; no change in position statement. Updated description section and references.

01/01/13

Annual CPT coding update. Revised code descriptor for 28890.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/17

Annual CPT/HCPCS update. Deleted 0019T.

09/15/17

Scheduled review. Revised description, added additional indications considered investigational (Achilles tendinitis, patellar tendinitis, and spasticity). Revised definitions. Updated references.

Date Printed: October 23, 2017: 02:13 AM