Emerging Concepts In Shockwave Therapy

By Lowell Weil, Jr., DPM, MBA

When musculoskeletal extracorporeal shockwave therapy (ESWT) was first introduced in the United States with the first FDA approval in 2000, there was a great deal of controversy and posturing among manufacturers of ESWT technologies. Each company was determined to create an exclusive market for their product at the expense of the competition. One of the most common targets for criticism was the level of energy of the technology. Based on industry biases, high-energy ESWT was considered the most effective for the musculoskeletal system. Those devices that failed to reach high energy were considered inferior.
Interestingly, there was no standard to measure energy levels and each technology measured its energy level differently. Accordingly, comparisons were not valid. When questioned as to which companies used high energy and which companies used low energy, physicists who were experts in ESWT usually were unable to answer the question because of the lack of standardization.
As the battle for differentiation continued, some of the companies claiming to have high-energy ESWT devices successfully differentiated themselves to the CPT coding committee and were able to receive a standard CPT code (28890) that required “high energy, performed under anesthesia other than local and using an ultrasonic targeting device for the treatment of plantar fasciitis.” At that time, research from outside of the United States tended to favor high-energy ESWT. While some insurance companies would not cover any ESWT, others would only cover “high-energy” ESWT based on the “flawed” research and an effective lobby by the more powerful ESWT companies.1
High-energy ESWT was often differentiated by the need for anesthesia other than local (intravenous sedation, ankle block -CPT 28890). The high-energy shockwave devices did have the advantage of providing treatment in one session but were also extraordinarily expensive to the patient with the combination of technology expense, procedural expense and anesthesia expense. Few private practitioners could afford the investment of a high-energy device and private partnerships emerged to make devices available on a rental basis. Unfortunately, the cost of high-energy ESWT became prohibitive to the insurance companies as well as to many patients.

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