Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve extracorporeal shock wave therapy (ESWT) (28890). 
 
You asked the Plan to pre-approve extracorporeal shock wave therapy (ESWT) (28890). You say that the 
requested extracorporeal shock wave therapy (ESWT) (28890) is medically necessary. The Plan denied your 
request. The Plan says that the requested extracorporeal shock wave therapy (ESWT) (28890) is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve extracorporeal shock wave therapy 
(ESWT) (28890). Our reviewer says that the requested extracorporeal shock wave therapy (ESWT) (28890) is 
medically necessary. Our physician reviewer found CMS guidelines advise that Medicare will pay for items or 
services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve 
the functioning of a malformed body member. This treatment must be safe and effective, not mainly for the 
convenience of the patient or the physician, not experimental or investigational, appropriate and furnished in 
accordance with accepted standards of medical practice for the diagnosis or treatment of the patients 
condition, one that meets, but does not exceed, the patients medical need, and at least as beneficial as existing 
and available medically appropriate alternatives. In this particular case the enrollee is diagnosed with 
recalcitrant right-sided painful proximal plantar fasciitis. Important to note in this case is that the enrollee has 
tried and failed numerous conservative treatments for their plantar fasciitis for greater than three years.  Prior 
treatments include changes in shoe gear, stretching, anti-inflammatory medications, multiple cortisone 
injections, night splints, and ultrasound treatment.  Because of the failure of the prior mentioned conservative 
treatments, ESWT is a reasonable treatment option that is proven to be at least as effective as the other 
conservative treatments that were attempted. ESWT is a nonsurgical treatment that is FDA approved. 
Therefore, the requested extracorporeal shockwave therapy (ESWT) (28890) is medically reasonable and 
necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal shock wave therapy (ESWT) (28890) have been met. Therefore, 
we decided that the Plan has to pre-approve extracorporeal shock wave therapy (ESWT) (28890).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.