Medicare (CMS LCD/NCD) Extracorporeal Shock Wave Therapy prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Extracorporeal Shock Wave Therapy (CPT 0101T, 0102T, 28890), for Medicare (NC) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Extracorporeal Shock Wave Therapy (CPT 0101T, 0102T, 28890). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Palmetto GBA LCD L38775 - Extracorporeal Shock Wave Therapy (ESWT) (revision effective 09/12/2024). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment that involves delivery of an acoustic shock wave to a specific area of the body. The objective of this treatment is to reduce pain and stimulate healing of the affected area. The acoustic waves travel through fluid and soft tissue, and their effects occur at sites where there is a change in impedance, such as the bone/soft-tissue interface. ESWT has become a proposed treatment option for specific musculoskeletal conditions. These conditions include, but are not limited to, calcific tendinopathy of the shoulder, elbow tendinopathy (lateral/medial epicondylitis), carpal tunnel syndrome (CTS), greater trochanteric pain syndrome (GTPS), fractures and delayed unions/nonunions, osteonecrosis of the femoral head (ONFH), and patellar tendinopathy (PT). The mechanism by which ESWT achieves a therapeutic intervention in musculoskeletal conditions is not completely known. Numerous hypotheses have been proposed: ESWT may disrupt fibrous tissue allowing for the subsequent promotion of revascularization and healing of tissue. Direct and indirect effects of the shock waves may damage cell membranes; reducing the ability of nociceptors to transmit pain signals 11 and/or promote healing. Shock waves break up calcium deposits, loosen structures, and promote resorption of calcium; thereby decreasing pain and improving function. This A/B MAC considers ESWT (high energy) not reasonable and necessary for the treatment of musculoskeletal conditions and therefore not covered. [NEEDS CLINICAL SPOT-CHECK]
How to submit
- Method: Traditional Medicare: no prior authorization in the office or ASC setting - bill Part B with documentation on file. If performed in a HOSPITAL OUTPATIENT DEPARTMENT, check the CMS OPD prior-authorization list for the specific code before the date of service. Medicare Advantage plans (Humana, UHC, Aetna, Blue Medicare) require their own PA but must apply this LCD's criteria under 42 CFR 422.101(b).
Sources & verification
- BindingSource - LCD: Extracorporeal Shock Wave Therapy (ESWT) (L38775) · effective 2024-09-12.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-09-20.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Extracorporeal Shock Wave Therapy?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Extracorporeal Shock Wave Therapy (CPT 0101T, 0102T, 28890). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Extracorporeal Shock Wave Therapy?
Palmetto GBA LCD L38775 - Extracorporeal Shock Wave Therapy (ESWT) (revision effective 09/12/2024). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment that involves delivery of an acoustic shock w… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Extracorporeal Shock Wave Therapy to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.