0101T — Esw muscskel sys nos
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- This policy supplements LCD L38775; claims must include the documentation and medical necessity evidence required by LCD L38775 (medical records, diagnoses, and any required prior authorizations).
- The article provides billing and coding guidance for ESWT (including applicable CPT/HCPCS codes and modifiers) — consult the full policy text for specific code listings and coding instructions.
- No explicit or itemized documentation requirements (medical records, tests, prior conservative treatments, etc.) are specified in this policy.
- Policy instructions require reference to the member-specific benefit plan document when deciding coverage: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan."
Key Coverage Criteria
- No clinical indications are specified in this billing/coding policy; refer to Local Coverage Determination L38775 for covered indications and medical necessity criteria for ESWT.
- "Extracorporeal shock wave therapy (ESWT), whether low energy, high energy, or radial wave, is unproven and not medically necessary for any musculoskeletal or soft tissue indications due to insufficient evidence of efficacy."
5 Active Policies
A58367 — Billing and Coding: Extracorporeal Shock Wave Therapy (ESWT)
L38775 — Extracorporeal Shock Wave Therapy (ESWT)
UHC-POL-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
UMR-POL-UMR-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
Related Codes
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