Does Medicare Cover Shock Wave Therapy for Plantar Fasciitis?
Navigating Medicare coverage for shock wave therapy for plantar fasciitis can be complex. Discover typical coverage status, financial implications, and appeal options.
Plantar fasciitis is a common condition causing heel pain, stemming from inflammation of the thick band of tissue on the bottom of the foot. Extracorporeal Shock Wave Therapy (ESWT) is a non-invasive treatment that delivers acoustic waves to the affected area, aiming to reduce pain and stimulate healing. Understanding Medicare’s coverage policies for ESWT for plantar fasciitis is important for beneficiaries considering this treatment.
How Medicare Covers Medical Services
Medicare Part B helps cover medically necessary outpatient services, including doctor visits, therapies, and durable medical equipment. A service is considered “medically necessary” if it meets accepted standards of medical practice to diagnose or treat a medical condition. This definition dictates what Medicare will cover.
Medicare determines coverage through National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). NCDs are national standards, while LCDs are set by regional Medicare contractors and reflect local medical norms for specific services or procedures. These determinations outline the specific conditions and criteria under which a service is covered. Medicare Advantage Plans (Part C) generally must cover at least the same services as Original Medicare.
Specific Coverage for Shockwave Therapy
Extracorporeal Shock Wave Therapy (ESWT) for plantar fasciitis is generally not covered by Original Medicare. There is currently no specific National Coverage Determination (NCD) for ESWT for musculoskeletal conditions like plantar fasciitis. Many Local Coverage Determinations (LCDs) also consider ESWT for plantar fasciitis to be investigational and unproven, or not reasonable and necessary, due to insufficient evidence of its effectiveness.
This means Medicare typically deems ESWT for plantar fasciitis as experimental, investigational, or not medically necessary. Even if a provider offers this service, patients would generally be responsible for the full cost if Medicare does not cover it. Medicare Advantage plans typically align with Original Medicare’s stance on services considered experimental or not medically necessary.
Understanding Your Financial Responsibility
When a service is covered by Medicare Part B, beneficiaries typically pay an annual deductible, and then a 20% coinsurance of the Medicare-approved amount for most services. However, if Medicare determines a service is not medically necessary or is experimental, the patient is generally responsible for 100% of the cost. This is often the case with ESWT for plantar fasciitis.
If a healthcare provider believes Medicare will not cover a service, they may issue an Advance Beneficiary Notice of Noncoverage (ABN). An ABN is a form that informs you Medicare may not pay for a specific item or service and estimates your potential financial liability. By signing an ABN, you acknowledge that you understand Medicare may deny the claim and agree to pay for the service yourself if Medicare does not cover it.
What to Do if Coverage is Denied
If a claim for shockwave therapy is denied by Medicare, beneficiaries have the right to appeal the decision. The Medicare appeals process involves several levels of review. The first step, Redetermination, is an initial review conducted by a Medicare Administrative Contractor (MAC). You typically need to file this request within 120 days of receiving the denial notice.
If you disagree with the Redetermination outcome, you can proceed to Reconsideration by a Qualified Independent Contractor (QIC). It is important to gather all relevant medical records and documentation from your doctor or provider to support your case throughout this process.