I. Disclaimer

This document is intended to be used as a reference for non-VA providers and not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice. 

II. Clinical Determinations and Indications

1. Indications for Extracorporeal Shock Wave Therapy
   Although high-energy extracorporeal shock wave therapy (ESWT) is generally considered investigational and experimental for the treatment of chronic plantar fasciitis and lateral epicondylitis of the elbow, it may be considered medically necessary/covered in limited circumstances. Indications and clinical criteria are described below. 

1. Indications for Treatment of Chronic Plantar Fasciitis 
2. High-energy ESWT may be considered medically necessary/covered for chronic plantar fasciitis when ALL the following conditions are met: 
   • A diagnosis of chronic plantar fasciitis for at least six months 
   • Veteran has progressed through and failed six months of appropriate conservative therapy for chronic plantar fasciitis 
     • Must have tried multiple, cohesive, and comprehensive conservative therapies 
       • E.g., Prosthetics (off the shelf inserts or night splint), pharmaceuticals (topical and/or oral nonsteroidal anti-inflammatory drugs (NSAIDs), supportive shoe gear, physical therapy, and/or stretching and icing three times a day 
   • Used in conjunction with standard treatment for chronic plantar fasciitis  

2. Indications for Treatment of Chronic Lateral Epicondylitis of the Elbow 
3. High-energy ESWT may be considered medically necessary/covered for chronic lateral epicondylitis of the elbow when ALL the following conditions are met: 
   • A diagnosis of chronic lateral epicondylitis 
   • Veteran has experienced elbow pain for six months 
   • Veteran has progressed through and failed to respond to at least two of following appropriate conventional methods for treating elbow pain: 
     • At least four weeks of physical/occupational therapy to include isometric and eccentric exercise  
     • At least four weeks course of NSAIDs 

2. Indications for Extracorporeal Shock Wave Therapy
3. Although high-energy extracorporeal shock wave therapy (ESWT) is generally considered investigational and experimental for the treatment of chronic plantar fasciitis and lateral epicondylitis of the elbow, it may be considered medically necessary/covered in limited circumstances. Indications and clinical criteria are described below. 
   • Low-energy ESWT 

• Conditions/indications for which high-energy ESWT is not medically necessary and not covered include, but are not limited to, the following: 
  • Calcific tendinopathy of the shoulder 
  • Achilles tendinopathy 
  • Iliotibial band (ITB) syndrome 
  • Medial elbow tendinopathies (medial epicondylitis) 
  • Greater trochanteric pain syndrome 
  • Patellar tendinopathy 
  • Fractures and delayed union/non-unions of the bone 
  • Osteonecrosis of the femoral head 
  • Erectile dysfunction  

For all other conditions or indications not listed in section II.a. of this document, high-energy ESWT is considered not medically necessary and not covered due to insufficient evidence of efficacy and safety. 

3. Description of Treatment 
   1. Extracorporeal shock wave therapy (ESWT) is a noninvasive treatment that uses acoustic shock waves to reduce pain and stimulate healing in the affected area. These effects may include osteogenic, neovascularization, protein synthesis, cell proliferation, and calcium destruction. Extracorporeal shock wave therapy is delivered at low, medium, or high energy levels. There are two types of shock waves: focal waves, which are higher intensity and penetrate deeper (electrohydraulic, piezoelectric, or electromagnetic with a negative phase), and radial waves, which are lower intensity, pneumatic without a negative phase, and act more superficially. 

      Extracorporeal shock wave therapy’s therapeutic mechanism in musculoskeletal conditions is not completely known; however, some theories include: 

      • The shock waves disrupt fibrous tissue and promote revascularization 
      • The shock waves break up calcified deposits, loosen structures, and promote calcium resorption, resulting in decreased pain and improved function 

III. Background and Supporting Information

1. Background Information 
2. Plantar Fasciitis 
3. Plantar fasciitis, defined as inflammation of the plantar fascia in the foot, is the most common condition causing heel pain and occurs in approximately 10% of the population in the United States. Plantar fasciitis may be caused by a number of factors, including the structure of the foot, heel cord (calf) and hamstring tightness, the type of shoes worn, use and overuse of the feet, conditioning, exercise technique, and the type of surface being walked on. This condition is usually diagnosed by a physical examination and review of medical history. Traditional treatment options often include stretching and physical therapy, icing and non-steroidal anti-inflammatory medications, and a combination of activity modification and orthotics. 
   

2. Research, Clinical Trials, and Evidence Summaries
3. Clinical studies have found extracorporeal shock wave therapy (ESWT) to be an effective treatment for some musculoskeletal conditions, such as chronic plantar fasciitis and chronic lateral epicondylitis of the elbow. This therapy has been found to be beneficial in patients when used in conjunction with other physical therapies. Extracorporeal shock wave therapy has proven to be a cost-effective treatment for plantar fasciitis while demonstrating long-term success.

Al-Siyabi et al. (2022) completed a systematic review and meta-analysis to compare the outcomes of ESWT versus ultrasound therapy for the treatment of plantar fasciitis. Seven studies, including randomized controlled trials and observational studies, resulted in a total of 369 patients. The results of this meta-analysis suggest that ESWT is a superior option over ultrasound therapy for the treatment of patients with plantar fasciitis. Outcomes showed ESWT was proven to improve the pain activity and intensity, primary efficacy success rate, activity limitations, and patient satisfaction. Additionally, ESWT does not worsen morning pain, functional impairment, American Orthopaedic Foot and Ankle Society (AOFAS) scale score, or plantar fascial thickness compared to ultrasound therapy. 

De la Corte-Rodríguez et al. (2023) performed a narrative review of current literature from PubMed, the Cochrane Database, EMBASE, CINAHL, and PEDro containing “ESWT for musculoskeletal pain (MSK).” A total of 3,517 studies were initially identified of which 93 were included in the final review. The reviewers aimed to provide updated information on the function of ESWT in the treatment of different pathologies that cause MSK pain. The purpose was to review possible new mechanisms of action, update the level of evidence for known indications, and assess possible new indications that have emerged in recent years. The current literature indicates ESWT is a safe and effective treatment for numerous MSK pathologies when conservative treatment has failed. Minimal adverse effects were reported. Extracorporeal shock wave therapy can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect. 

Tognolo et al. (2022) studied plantar fasciitis in an open label randomized control clinical trial. Thirty patients were included in this limited study. It was noted that ESWT was used on the plantar facia as well as several myofascial points of the entire effected limb. It was hypothesized that plantar fasciitis was a result of an altered force along the entire body system and needed correction in multiple areas to alleviate pain. During the study, patients who received ESWT were found to have an overall reduction in pain. This limited study showed favorable results in recovery time and pain reduction through ESWT treatment and may indicate ESWT is more effective when used for “re-equilibrium of the body.” 

Schroeder et al. (2021) outlined management guidelines and recommendations for use of ESWT in sports medicine injuries. The team highlights that although lateral epicondylitis is an FDA-approved indication for ESWT, current studies show mixed treatment efficacy. A meta-analysis of five randomized controlled trials comparing ESWT to ultrasound therapy showed statistically significant improvement in short-term pain and grip strength. The recommendation from this guideline is treatment of lateral epicondylitis may be indicated in cases in which other therapies have been unsuccessful. Extracorporeal shock wave therapy has been found to significantly improve short term pain (at one, three, and six months) and grip strength (at three months) but not in function (one to three months) compared to ultrasound. Extracorporeal shock wave therapy can be painful during treatment of lateral epicondylitis and may not always be tolerated. It is recommended to adjust the energy level to keep the patient’s pain level tolerable and to consider starting at a lower energy level with gradual increase in dosage. 

Çayan et al. (2026) conducted a systematic review and meta-analysis of 12 randomized controlled trials evaluating low‑intensity shock wave therapy (LiSWT) for erectile dysfunction (ED), comparing the treatment with sham or no intervention. The analysis found that LiSWT produced modest but statistically significant improvements in patient‑reported erectile function, specifically increasing IIEF‑5 (SMD 1.19; 95% CI 0.47–1.91) and IIEF‑EF scores (SMD 1.24; 95% CI 1.02–1.45). However, no significant improvements were observed in erection hardness, sexual encounter profile outcomes, global assessment, or penile Doppler vascular parameters such as peak systolic velocity, end‑diastolic velocity, and resistive index. The authors concluded that while LiSWT may offer limited benefit in self‑reported erectile function, its overall clinical relevance is low due to the lack of meaningful functional or vascular improvements, and therefore current evidence does not support its routine use in ED treatment pathways; they recommend further research to identify patient subgroups that may derive more substantial benefit. 

3. U.S. Food & Drug Administration Information
4. VA generally only approves use of medical devices that have received at least Food & Drug Administration (FDA) clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices and may be marketed in the U.S. 
5. To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database. 

4. Medicare Coverage Determinations 
5. Available Medicare national and local coverage determinations are listed below as a resource. VA and Medicare are governed by separate laws and regulations; thus, VA coverage determinations may be different. 

6. LCD Number	Contractor	Original/Revision Effective Date
   L38775	Palmetto GBA	09/12/2024

   NCD Number	Name	Effective Date
   None	N/A	N/A

• NCD: National Coverage Determination 
• LCD: Local Coverage Determination  

5. TRICARE Policy Manual 
6. Available TRICARE coverage determinations are listed below as a resource. VA and TRICARE are governed by separate laws and regulations; thus, VA coverage determinations may be different. 
7. TRICARE Policy Manual 6010.60-M, Chapter 4, Section 6.1 
   • 4.8: High Energy Extracorporeal Shock Wave Therapy for the treatment of plantar fasciitis is covered when all of the following conditions are met: 
     • Patients have chronic plantar fasciitis of at least six months duration 
     • Patients have undergone and failed six months of appropriate conservative therapy; and 
     • HE ESWT is defined as Energy Flux Density greater than 0.12 millijoules per square millimeter (mJ/mm2) 
   • 5.8: Low Energy or radial ESWT for the treatment of plantar fasciitis is unproven. Any form of ESWT for the treatment of lateral epicondylitis is unproven 

6. Health Care Procedural Coding Information 
7. The following CPT^®/HCPCS codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) code updates may occur more frequently than CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for medical necessity. 

The following CPT codes may be considered medically necessary/covered if the indications and clinical criteria outlined in section II.a. are met. Additional codes may also apply. 

CPT Code	Description
0101T	Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia

CPT copyright 2024 American Medical Association. All rights reserved. 

IV. Definitions

Term	Definition
Eccentric strengthening exercises	Exercises that focus on movements, or phases of a movement, that lengthen the muscles
Osteonecrosis	A condition in which a lack of blood supply causes the bone to be deprived of nutrients and decay

V. References

Al-Siyabi, Z., Karam, M., Al-Hajri, E., Alsaif, A., Alazemi, M., & Aldubaikhi, A. A. (2022). Extracorporeal Shockwave Therapy Versus Ultrasound Therapy for Plantar Fasciitis: A Systematic Review and Meta-Analysis. Cureus, 14(1), e20871.  

Auersperg, V., & Trieb, K. (2020). Extracorporeal shock wave therapy: an update. EFORT open reviews, 5(10), 584–592. 

Çayan, S., Pinggera, G. M., Alipour, H., Shah, R., Şahin, B., Altay, B., Mostafa, T., Dimitriadis, F., Dardmeh, F., Kumar, N., Alarcon, D. C. A., Fathalla, N., Sheibak, N., Rahman, S. M., Gouri, A., Moreno-Sepulveda, J., Daoud, S., Anagnostopoulou, C., Ryzhkov, A., Toprak, T., … Agarwal, A. (2026). Effects of Low-Intensity Shock Wave Therapy on Erectile Function and Penile Vascular Parameters in Men with Erectile Dysfunction: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. The world journal of men’s health, 10.5534/wjmh.250266. Advance online publication. 

De la Corte-Rodríguez, H., Román-Belmonte, J. M., Rodríguez-Damiani, B. A., Vázquez-Sasot, A., & Rodríguez-Merchán, E. C. (2023). Extracorporeal Shock Wave Therapy for the Treatment of Musculoskeletal Pain: A Narrative Review. Healthcare (Basel, Switzerland), 11(21), 2830. 

Defense Health Agency (2015). Musculoskeletal System. TRICARE Policy Manual 6010.60-M. Chapter 4, Section 6.1. Retrieved September 25, 2023.

The International Society for Medical Shockwave Treatment. (2022). Introduction and prerequisites and minimal standards of performing ESWT. Retrieved June 20, 2023.

Johns Hopkins Medicine. (n.d.). Plantar Fasciitis. Retrieved February 26, 2024.

MCG Health. (2023). Extracorporeal Shock Wave Therapy, Musculoskeletal. Ambulatory Care. 27th Edition. 

Medicare Coverage Database (n.d.). Retrieved March 24, 2026.

Schroeder, A. N., Tenforde, A. S., & Jelsing, E. J. (2021). Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries. Current sports medicine reports, 20(6), 298–305. 

Tenforde, A. S., Borgstrom, H. E., DeLuca, S., McCormack, M., Singh, M., Hoo, J. S., & Yun, P. H. (2022). Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration. PM & R : the journal of injury, function, and rehabilitation, 14(5), 611–619. 

Tognolo, L., Giordani, F., Biz, C., Bernini, A., Ruggieri, P., Stecco, C., Frigo, A. C., & Masiero, S. (2022). Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial. European journal of physical and rehabilitation medicine, 58(1), 85–93. 

VI. CDI History/Revision Information

Date	Summary of Updates
07/01/2026	Updated indications and clinical criteria for Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions  Added “to include isometric and eccentric exercise” to the following criteria: “At least four weeks of physical/occupational therapy to include isometric and eccentric exercise”  Removed “local steroid injections”  Updated limitations and exclusions for Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions  Added “erectile dysfunction”  Added “Health Care Procedural Coding Information” section  Updated “Research, Clinical Trials, and Evidence Summaries” section   Added Çayan et al. (2026)
11/04/2024	New CDI created describing medically necessary / not medically necessary indications

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