Table: CPT Codes / HCPCS Codes / ICD-10 Codes CodeĬPT codes covered if selection criteria are met:Įxtracorporeal pulse activation therapy (EPAT) - no specific code:Įxtracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energyĬPT codes not covered for indications listed in the CPB:Įxtracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyleĮxtracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing careĮxtracorporeal 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 CPB 0235 - Plantar Fasciitis Treatments.Other musculoskeletal indications (e.g., calcaneal spur, Hammer toe, tenosynovitis of the foot or ankle, and tibialis tendinitis).Īetna considers pre-operative ESWT for reduction of scar formation following abdominoplasty surgery experimental and investigational because the effectiveness of this approach has not been established.Wound healing (including burn wounds and soft tissue wounds).Subacromial impingement syndrome/subacromial shoulder pain.Spasticity associated with brain injury/stroke, or cerebral palsy.Snapping scapula (scapula-thoracic bursitis).Rotator cuff tendonitis (shoulder pain).Neurogenic heterotopic ossification following traumatic brain injury.Myofascial pain syndrome of the trapezius.Lower limb ulceration (e.g., venous leg ulcers).Lower limb conditions (e.g., Achilles tendinopathy, greater trochanteric pain syndrome, knee tendinopathy, medial tibial stress syndrome, patellar tendinopathy and proximal hamstring tendinopathy).Hypertrophic scars of the hand caused by burn injury.Chronic kidney disease (other than kidney stones).

Acute fractures (complete fractures or st ress fractures).This Clinical Policy Bulletin addresses extracorporeal shock-wave therapy for musculoskeletal indications and soft tissue injuries.Īetna considers extracorporeal shock-wave therapy (ESWT) medically necessary for calcific tendinopathy of the shoulder of at least 6 months’ duration with calcium deposit of 1 cm or greater, and who have failed to respond to appropriate conservative therapies (e.g., rest, ice application, and medications).Īetna considers extracorporeal shock-wave therapy (ESWT), extracorporeal pulse activation therapy (EPAT) (also known as extracorporeal acoustic wave therapy) experimental and investigational for the following indications (not an all-inclusive list) because there is insufficient evidence of effectiveness of ESWT for these indications in the medical literature: Number: 0649 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

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