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Medical Policy: 02.01.09
Original Effective Date: July 2001
Reviewed: May 2012
Revised: May 2012
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Heel pain is the most common area of pain in the foot, particularly upon arising from bed in the morning. The exact cause of Plantar Fasciitis is not known although repetitive injury is suspected. Patients with Plantar Fasciitis show a high incidence of bony plantar heel spurs, although it has never been proven that heel spurs are the cause of the pain.
Conservative therapies, rest, minimization of running or jumping, heel cups and nonsteroidal anti inflammatory drugs are successful in the majority of the cases of Plantar Fasciitis.
Extracorporeal shock wave treatment (ESWT) has been available for the treatment of renal stones and biliary stones since the 1980's. The acoustic forces of a shock wave are utilized to cause the disintegration of brittle material, i.e. calcified stones. The same technology is being investigated as a treatment of Plantar Fasciitis and other musculoskeletal diseases such as lateral epicondylitis (tennis elbow) and delayed union or non-union of bone fractures. It is also being studied in the treatment of soft tissue injuries, including wounds and ulcers.
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Prior Approval:
Not applicable
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Policy:
ESWT is considered investigational for the treatment of Plantar Fasciitis and all other musculoskeletal conditions, including, but not limited to, lateral epicondylitis, tendinopathies including calcific tendinitis of the shoulder, stress fractures, delayed union and nonunion of fractures, and avascular necrosis of the femoral head.
ESWT is considered investigational for the treatment of soft tissue injuries, including but not limited to wounds and chronic ulcers.
Data as to the effectiveness (impact on net health outcome) of ESWT in the treatment of musculoskeletal conditions and soft tissue injuries remains inconclusive, including in the FDA-approved indications for plantar fasciitis and lateral epicondylitis. Differences in treatment parameters among studies, including energy dosage, method of generating and directing shock waves, and use or absence of anesthesia, limit generalizations from results of multiple studies. The precise mechanism of action of ESWT and impact of anesthesia on outcomes continue to be matters of discussion.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 0019T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy
- 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 lateral humeral epicondyle
- 28890 Extracorporeal shock wave, high energy, performed by a physician involving the plantar fascia
- 0299T Extracorporeal shock wave for integumentary wound healing, high energy including topical application and dressing care; initial wound
- 0300T Extracorporeal shock wave for integumentary wound healing, high energy including topical application and dressing care; each additional wound
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Selected References:
- Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. The Journal of Bone and Joint Surgery 1999 September; 81-B:863-86.
- Atkins D, Crawford EF, Edwards J, Lambert M. A systematic review of treatments for the painful heel. Rheumatology 1999;38:968-973.
- Maier M, Steinborn M, Schmitz C, Stabler A, Kohlet S, Pfahler M, Durr HR, Refior HJ. Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: Prediction of outcome by magnetic resonance imaging. Journal of Rheumatology 2000;27:2455-2462.
- Huang HH, Qureshi AA, Biundo JJ. Sports and other soft tissue injuries, tendinitis, bursitis and occupational-related syndromes. Current Opinion in Rheumatology2000;12:150-154.
- Ogden JA, Alvarez R, Levitt R et al. Shock wave therapy for chronic proximal plantar fasciitis. Clinical Orthopedics and Related Research 2001;387:47-59.
- 2001 TEC assessment: Extracorporeal Shock Wave treatment for musculoskeletal indications.
- Cosentino R, Falsetti P, Manca S et al. Efficacy of extracorporeal shock wave treatment in calcaneal enthesophytosis. Annals of the Rheumatic Diseases 2001;60:1064-1067.
- Rompe JD, Hopf C, Nafe B et al. Low energy extracorporeal shock wave treatment in calcaneal enthesophytosis. Annals of the Rheumatic Diseases 1996;115:75-79.
- Chen LM, Liang-Mei HC, Huang TW. Treatment of painful heel syndrome with shock waves. Clinical Orthopedics and Related Research 2001;387:41-46.
- Speed CA, Richards C, Nichols D, Burnet S, Wies JT, Humphreys H, Hazelman BL. Extracorporeal shock-wave therapy for tendonitis of the rotator cuff. A double blind, randomized controlled trial. J Bone Joint Surg Br 2002 May;84(4) 509-12.
- Buchbinder R, Ptasznik R, Gordon J, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA 2002; 288(11): 1364 – 72.
- Weil LS, et al. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results and a comparison of results to fasciotomy. J of Foot & Ankle Surgery May/June 2002; 41 (2) 166-172.
- Haake M Buch M, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomized controlled multicentre trial. BMJ. 2003 Jul 12;327(7406):75.
- Speed CA, Nichols D, et al. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomized controlled trial. J Orthop Res. 2003 Sep;21(5):937-40.
- Biel M, Donahue J, et al. Technology Assessment Report: Extracorporeal Shock Wave Therapy for Plantar Fasciitis. Institute for Clinical Systems Improvement TA #86 November 2004.
- Speed CA, Nichols D, et al. Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial. J Orthop Res. 2002 Sep;20(5):895-8.
- Chung B, Wiley JP, Rose MS. Long-term effectiveness of extracorporeal shockwave therapy in the treatment of previously untreated lateral epicondylitis. Clin J Sport Med. 2005 Sep;15(5):305-12.
- Buchbinder R, Green SE, et al. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheumatol. 2006 Jul;33(7):1351-63.
- Malay DS, Pressman MM, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006 Jul-Aug;45(4):196-210.
- ECRI Institute. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Plymouth Meeting (PA): ECRI Health Information Technology Service; Windows on Medical Technology; November 2006; Issue No. 140.
- ECRI. Extracorporeal Shock Wave Therapy for the Treatment of Plantar Fasciitis. Plymouth Meeting (PA): ECRI Health Information Technology Service; 2007 August 17. 8 p. (ECRI) Hotline Response). Also available: http://www.ecri.org.
- Marx RC, Mizel MS. What’s new in Foot and Ankle Surgery. J Bone Joint Surg Am. 2008 April;90:928-942.
- ECRI Institute. Extracorporeal Shockwave Therapy for the Treatment of Plantar Fasciitis. Plymouth Meeting (PA): ECRI Institute; 2009 July 24. 9 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave therapy for refractory greater trochanteric pain syndrome. Interventional Procedure Guidance 376. London, UK: NICE; January 2011.
- ECRI Institute. Extracorporeal Shockwave Therapy for Shoulder Tendonitis. Plymouth Meeting (PA): ECRI Institute’s Health Technology Assessment Information Service; 2011 September 7. [Hotline Response]. Also available: http://www.ecri.org.
- ECRI Institute. Extracorporeal Shockwave Therapy for the Treatment of Plantar Fasciitis. Plymouth Meeting (PA): ECRI Institute’s Health Technology Assessment Information Service; 2011 July 5. [Hotline Response]. Also available: http://www.ecri.org.
- Ottomann C, Stojadinovic A, Lavin PT, et al. Prospective randomized phase II Trial of accelerated reepithelialization of superficial second-degree burn wounds using extracorporeal shock wave therapy. Ann Surg. 2012 Jan; 555(1):23-9.
- Huisstede BM, Gebremariam L, van der Sande R, et al. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis—a systematic review. Man Ther. 2011 Oct; 16(5): 419-33.
- Wang CF, Wu RW, Yang YJ. Treatment of diabetic foot ulcers: a comparative study of extracorporeal shockwave therapy and hyperbaric oxygen therapy. Diabetes Res Clin Pract. 2011 May; 92(2):187-93.
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Policy History:
Date Reason Action
June 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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