Does Medicare Cover Shockwave Therapy?

Shockwave therapy is a non-invasive medical procedure that uses acoustic waves to stimulate healing in various tissues, aiming to reduce pain, improve circulation, and promote tissue regeneration. Often, it is considered for chronic pain and musculoskeletal conditions that have not responded to conventional treatments. Medicare, a federal health insurance program, provides coverage primarily for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS).

Medicare’s Approach to New Therapies

Medicare evaluates new medical services and procedures to determine coverage. The program generally covers items and services considered “reasonable and necessary” for diagnosis, treatment, or to improve functioning. This assessment reviews a therapy’s medical necessity, proven safety, and effectiveness based on clinical evidence.

The Centers for Medicare & Medicaid Services (CMS) establishes national coverage policies through National Coverage Determinations (NCDs). These NCDs apply uniformly across the United States. In the absence of an NCD, Medicare Administrative Contractors (MACs) may issue Local Coverage Determinations (LCDs), which define coverage criteria within their specific regional jurisdictions.

A service is not automatically covered by Medicare simply because a physician recommends it or because it has received FDA approval. While FDA approval confirms a device’s safety and effectiveness, Medicare independently evaluates if the service is medically reasonable and necessary. Establishing an NCD can take nine to twelve months for thorough evidence review and public participation.

Specific Medicare Coverage Rules for Shockwave Therapy

Medicare does not cover extracorporeal shockwave therapy (ESWT) for many musculoskeletal conditions. For instance, shockwave therapy for plantar fasciitis is not covered, as Medicare deems it not medically necessary or reasonable. This non-coverage extends to other musculoskeletal indications and soft tissue injuries, which Medicare often considers investigational or unproven due to insufficient evidence.

ESWT is not covered for conditions including tendinopathies of the shoulder, elbow (lateral epicondylitis), Achilles tendinitis, and patellar tendinitis. Coverage is also denied for stress fractures, delayed or non-union of fractures, and avascular necrosis of the femoral head. The use of CPT codes, such as 0101T or 0102T, does not guarantee Medicare coverage; it is determined by medical necessity and Medicare’s policies.

For erectile dysfunction (ED), Medicare does not cover shockwave therapy, considering it an investigational treatment. While a new CPT code (X170T) for low-intensity ESWT for ED became available in 2024 to facilitate billing, its existence does not mean Medicare provides reimbursement; it allows for tracking and potential coverage by other payers. For most common applications in musculoskeletal pain and ED, beneficiaries should anticipate that Medicare will not reimburse shockwave therapy.

Patient Responsibilities and Next Steps

Medicare beneficiaries considering shockwave therapy should discuss the procedure’s medical necessity with their physician. Inquire about the specific diagnosis and CPT codes the provider intends to use for billing. This clarifies how the service will be presented to Medicare.

Beneficiaries should verify their coverage before receiving any shockwave therapy. This is especially important for those in a Medicare Advantage (Part C) plan, as these private plans may have different network restrictions, prior authorization, or coverage rules than Original Medicare. Contacting the plan directly confirms specific benefits and potential out-of-pocket costs.

If a service is expected to be denied by Medicare, the provider may issue an Advance Beneficiary Notice of Noncoverage (ABN). This form, CMS-R-131, informs the patient that Medicare is unlikely to pay and transfers financial responsibility. By signing an ABN, the patient acknowledges potential full cost responsibility if Medicare denies the claim, or they can decline the service. Even if covered in rare circumstances, Original Medicare Part B beneficiaries are responsible for the annual deductible and a 20% coinsurance.