Anthem Blue Cross ConnecticutCommercial Clinical Policy

SURG.00045 Extracorporeal Shock Wave Therapy Form

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Effective Date

12/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the use of extracorporeal shock wave therapy (ESWT), including Extracorporeal Pulse Activation Therapy (EPAT®), for the treatment of musculoskeletal conditions, soft tissue injuries, and erectile dysfunction.

Note: This document does not address extracorporeal shock wave lithotripsy.

Position Statement

Investigational and Not Medically Necessary:

Use of Extracorporeal Shock Wave Therapy (ESWT), including but not limited to the use of Extracorporeal Pulse Activation Therapy (EPAT®), for the treatment of musculoskeletal conditions and soft tissue injuries is considered investigational and not medically necessary. These conditions include, but are not limited to:

  • Chronic plantar fasciitis
  • Calcified tendinitis of shoulder
  • Chronic lateral epicondylitis (tennis elbow)
  • Elbow tendinitis
  • Erectile dysfunction
  • Fixation of loosened cemented orthopedic prosthesis
  • Non-union fractures
  • Peyronie’s disease
  • Soft tissue or wound repair