Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
DESCRIPTION
High-energy extracorporeal shock wave therapy is a noninvasive procedure used in the management of gallstones and kidney stones. In these settings, the acoustic force of a shock wave causes the disintegration of brittle material (i.e., calcified stones). Subsequently extracorporeal shock wave is known as "orthotripsy". This therapy has also been investigated in the treatment of musculoskeletal conditions including epicondylitis, plantar fasciitis, tendinopathies, and nonunion of fractures.
Shock waves can be generated at different energy levels. High-energy (HE) ESWT in the treatment of plantar fasciitis is intended to disrupt tissues that cause pain and to stimulate neoangiogenesis, inflammatory response, and tissue regeneration healing. Low-energy (LE) ESWT is intended to cause an analgesic effect.
Examples of high-energy orthotripsy devices include OssaTron® and Dornier Epos™Ultra. Dornier Epos™ Ultra also includes low energy settings.
POLICY
High-energy extracorporeal shock wave therapy for the treatment of plantar fasciitis is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below).
High-energy extracorporeal shock wave therapy for the treatment of other musculoskeletal conditions including, but not limited to, the following is considered investigational:
Epicondylitis (i.e., tennis elbow)
Nonunion fractures
Tendinopathies (e.g., tendinitis of the shoulder, tendinitis of the supraspinatus)
Low-energy extracorporeal shock wave therapy is considered investigational.
Any orthotripsy device utilized for this procedure must have FDA approval specific to the indication, otherwise its use will be considered investigational.
MEDICAL APPROPRIATENESS
High-energy extracorporeal shock wave therapy for the treatment of plantar fasciitis is considered medically appropriate if ANY ONE of the following criteria are met:
Request for initial high-energy extracorporeal shock wave therapy with ALL of the following:
Treatment is on only one side at a time
Heel pain continuing for six months after failing ANY ONE of the following:
Treatments with a minimum of two cortisone injections
Treatment for three months with NSAIDS
Other potential causes of heel pain are undetected by x-rays or other appropriate imaging studies
Failed heel pain treatment with a conservative modality for a minimum of six weeks with ANY ONE of the following:
Arch supports
Casting (e.g., short leg walking cast)
Custom molded foot orthotics
Night splints
Over-the-counter orthotics, heel cup, or heel cushion
Soft inserts
Stretching
Trial of change of shoe style to oxford or running shoes
Walking boot
Request for repeat high-energy extracorporeal shock wave therapy with ALL of the following:
Persistent plantar fasciitis symptoms occurring a minimum of six months after the approved initial treatment has been performed
Treatment is only for one side at a time
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Published studies show conflicting information regarding the effectiveness and outcomes in the treatment of extracorporeal shock wave therapy for other musculoskeletal conditions including but not limited to epicondylitis or tendinopathy. There is a lack of validation for the optimal treatment parameters, the patient selection criteria, or the long-term effects of extracorporeal shock wave therapy for the treatment of other musculoskeletal conditions and for low-energy therapy.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2008). Extracorporeal Shock wave treatment for plantar fasciitis and other musculoskeletal conditions (2.01.40). Retrieved December 22, 2009 from BlueWeb. (34 articles and/or guidelines reviewed)
BlueCross BlueShield of Tennessee network physicians. November 2005.
Buchbinder R, Green SE, Youd JM, Assendelft WJJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003524.pub2. DOI: 10.1002/14651858.CD003524.pub2.
Crawford F, Thomson C. Interventions for treating plantar heel pain. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD000416. DOI: 10.1002/14651858.CD000416.
ECRI Institute. Health Technology Information Service. Windows on Medical Technology™. (2006, November). Extracorporeal shockwave therapy for treatment of plantar fasciitis. Retrieved December 31, 2009 from ECRI Institute. (119 articles and/or guidelines reviewed)
Hayes. Medical Technology Directory. (2005, August). Extracorporeal shock wave therapy for chronic plantar fasciitis. Retrieved December 31, 2009 from http://Hayesinc.com/subscribers. (46 articles and/or guidelines reviewed)
Hayes. Medical Technology Directory. (2005, August). Extracorporeal shock wave therapy for tendonitis of the rotator cuff. Retrieved December 31, 2009 from http://Hayesinc.com/subscribers. (37 articles and/or guidelines reviewed)
Johnson,G., Cadwallader, K., Scheffel, S., & Epperly, T. (2007). Treatment of lateral epicondylitis. American Family Physician, 76 (6), 843 - 848. (Level 5 Evidence)
Kudo, P., Dainty, K., Clarfield, M., Coughlin,L., Lavoie, P., & Lebrun, C. (2006).Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracorporeal shockwave therapy (ESWT) device: a North American confirmation study. Journal of Orthopedic Research, 24(2), 115 - 123. (Level 2 Evidence)
National Guideline Clearinghouse. American College of Occupational and Environmental Medicine (ACOEM). (2007 August). Elbow disorders. Retrieved December 31, 2009 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10883&string=extracorporeal+AND+shock+AND+wave+AND+therapy+AND+musculoskeletal+AND+conditions.
National Guideline Clearinghouse. Work Loss Data Institute. (2008 November). Ankle and foot (acute and chronic). Retrieved December 31, 2009 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12657&string=extracorporeal+AND+shock+AND+wave+AND+therapy+AND+musculoskeletal+AND+conditions.
National Guideline Clearinghouse. Work Loss Data Institute. (2009 January). Knee and leg (acute and chronic). Retrieved December 31, 2009 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12673&string=extracorporeal+AND+shock+AND+wave+AND+therapy+AND+musculoskeletal+AND+conditions.
National Institute for Health and Clinical Excellence. (2009, August). Extracorporeal shockwave therapy for refractory Achilles tendinopathy. Retrieved December 31, 2009 from http://www.nice.org.uk/nicemedia/pdf/IPG312Guidance.pdf.
National Institute for Health and Clinical Excellence. (2009, August). Extracorporeal shockwave therapy for refractory tennis elbow. Retrieved December 31, 2009 from http://www.nice.org.uk/nicemedia/pdf/IPG313Guidance.pdf.
National Institute for Health and Clinical Excellence. (2009, August). Extracorporeal shockwave therapy for refractory plantar fasciitis. Retrieved December 31, 2009 from http://www.nice.org.uk/nicemedia/pdf/IPG311Guidance.pdf.
Simpson, M., & Howard, T. (2009). Tendinopathies of the foot and ankle. American Family Physician, 80 (10), 1107 - 1114. (Level 5 Evidence)
U. S. Food and Drug Administration. (2005. April). Center for Devices and Radiological Health. Summary of safety and effectiveness data for extracorporeal shock wave therapy device P040026. Retrieved December 31, 2009 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=p040026.
ORIGINAL EFFECTIVE DATE: 10/1998
MOST RECENT REVIEW DATE: 2/11/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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AdditionalKeywords: Orthotripsy