EXTRACORPOREAL SHOCK WAVE THERAPY FOR MUSCULOSKELTAL CONDITIONS HS-037
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
Policy Number: HS-037 Original Effective Date: 8/7/2008 Revised Date(s): 7/21/2009; 7/28/2010;
8/2/2011; 7/5/2012; 7/11/2013; 7/10/2014;
6/5/2015
Easy Choice Health Plan, Inc.
Harmony Health Plan of Illinois, Inc.
Missouri Care, Inc.
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
WellCare Health Insurance of Illinois, Inc.
WellCare Health Plans of New Jersey, Inc.
WellCare Health Insurance of Arizona, Inc.
WellCare of Florida, Inc.
WellCare of Connecticut, Inc.
WellCare of Georgia, Inc.
WellCare of Kentucky, Inc.
WellCare of Louisiana, Inc.
WellCare of New York, Inc.
WellCare of South Carolina, Inc.
WellCare of Texas, Inc.
WellCare Prescription Insurance, Inc.
Windsor Health Plan
Windsor Rx Medicare Prescription Drug Plan APPLICATION STATEMENT
The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.
EXTRACORPOREAL SHOCK WAVE THERAPY FOR MUSCULOSKELTAL CONDITIONS HS-037
DISCLAIMER
The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs.
BACKGROUND
Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment option for musculoskeletal conditions that have failed to respond to conservative treatment. ESWT uses technology similar to lithotripsy in an attempt to relieve musculoskeletal symptoms of the specified affected area. The exact mechanism by which ESWT works is not known.
There are two theories on the therapeutic effects of the shock waves. One theory is that the shock waves alleviate pain by increasing blood flow and decreasing inflammation in the affected area. Another theory is that the shock waves damage cell membranes thus interfering with the transmission of pain signals.
Use of focused ultrasound waves in treatment of musculoskeletal conditions has been mainly for chronic calcific tendonitis in the shoulder, chronic tennis elbow and painful heel due to so-called plantar fasciitis. All these conditions have high rates (70-90%) of successful treatment with simpler, less expensive and more convenient methods of non- invasive medical or orthotic treatment, although there is no clear consensus on the superiority of one approach over another. Relatively small numbers of such cases are recalcitrant, unresponsive to rest, physical therapy, oral medication, injection of local anesthetics and corticosteroids, splints or plaster casts, heel cushions and heel cups.
Surgical methods, whether open or endoscopic, give frequent though inconsistent improvement in responsive cases, but are regarded in the orthopedic community as measures of last resort. (CMS, 2011).
Experience with ESWT in the treatment of musculoskeletal conditions is limited. This treatment method appears to offer benefit in some published case series, but has not been confirmed in random case controlled studies.
POSITION STATEMENT
Applicable To:
Medicaid – All Markets Medicare – All Markets
Extracorporeal shock wave therapy (ESWT) is considered experimental and investigational for musculoskeletal conditions.
ESWT is considered not medically necessary as primary treatment for the musculoskeletal conditions mentioned above. It may be considered medically necessary only in those cases in which there has been a demonstrated failure of vigorous conservative therapy after six months of treatment and only in those cases in which it is being provided as an alternative to surgical treatment.
ESWT is indicated for use for plantar fasciitis (refer to InterQual criteria Procedures Adult Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT).
CODING
Non Covered CPT* Codes
28890 Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
0019T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy
Clinical Coverage Guideline page 2
Original Effective Date:8/7/2008 - Revised: 7/21/2009, 7/28/2010, 8/2/2011, 7/5/2012, 7/11/2013, 7/10/2014, 6/5/2015
EXTRACORPORE
AL SHOCK WAVE THERAPY FOR MUSCULOSKELTAL CONDITIONS HS-037
0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy 0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than
local, involving humeral epicondyle HCPCS Codes – No applicable codes.
ICD-9-CM Procedure Codes –No applicable codes.
DRAFT ICD-10-PCS Codes – No applicable codes.
Non-covered ICD-9-CM Diagnosis Codes – All diagnosis codes are not covered.
Non-covered Draft ICD-10-CM Diagnosis Codes – All diagnosis codes are not covered.
*Current Procedural Terminology (CPT) 2015 American Medical Association: Chicago, IL.®©
REFERENCES
1. Centers for Disease Control and Prevention. (2011, January 24). Local coverage determination for Extracorporeal shock wave therapy (ESWT) for musculoskeletal indications (Palmetto GBA, L31551). Retrieved from http://www.cms.hhs.gov/mcd/search.asp
MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS
Date Action
6/5/2015, 7/10/2014, 7/11/2013 Approved by MPC. No changes.
7/5/2012 Approved by MPC. Revised name for clarification. Added CMS reference and note of coverage for the use of ESWT for plantar fasciitis; refer to 2012 InterQual criteria.
12/1/2011 New template design approved by MPC.
8/2/2011 Approved by MPC. No changes.
Clinical Coverage Guideline page 3
Original Effective Date:8/7/2008 - Revised: 7/21/2009, 7/28/2010, 8/2/2011, 7/5/2012, 7/11/2013, 7/10/2014, 6/5/2015
