28890
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
3.36
Facility
$205.75
Non-Facility
$303.95
Documentation Required
- 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."
- Before applying the policy, check member-specific benefit plan document and applicable federal or state mandates: "Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- Documentation of failure to respond to appropriate conservative therapies (examples provided: rest, ice application, and medications).
Key Coverage Criteria
- "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."
- Tendon injuries and general tendinopathies
- Achilles tendinopathy (insertional and chronic Achilles tendinopathy)
- Medial epicondylitis
- Plantar fasciitis
- Greater trochanteric pain syndrome
7 Active Policies
AETNA-CPB-0235 — Plantar Fasciitis Treatments
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
SUREST-POL-SUREST-extracorporeal-shock-wave-therapy — Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications
Related Codes
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