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Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries (CPB 0649, reviewed 2025-10-02)
Effective date
Not stated in the notice
Identified
Aug 15, 2026
Summary
This is Aetna Clinical Policy Bulletin 0649, reviewed October 2, 2025 and first found by PolicyChanges in August 2026, so it is historical material and the current version should be confirmed before acting. Aetna covers extracorporeal shock-wave therapy only for calcific tendinopathy of the shoulder with a calcium deposit of at least 1 cm lasting 6 months or more after conservative care has failed, and lists dozens of other musculoskeletal, wound and medical uses as experimental, investigational or unproven.
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What to do
Action · 4 steps
01Billing team: Before billing shockwave therapy for shoulder calcific tendinopathy (M75.30 to M75.32), confirm the chart shows a calcium deposit of 1 cm or more, symptoms for at least 6 months, and failed conservative treatment such as rest, ice and medication, and check the current version of Aetna CPB 0649 because this copy is from October 2025.
02Subacromial impingement (M75.40 to M75.92 range) is listed as not covered for this therapy, so do not use shockwave codes for that diagnosis in charge entry.
03For the other indications on the list, including plantar fascia shockwave (CPT 28890), lateral and medial epicondylitis, low back pain, knee arthritis and wound healing, Aetna lists the therapy as experimental, investigational or unproven, so confirm coverage with the current policy before scheduling.
04Providers and front desk staff: Tell orthopedic, sports medicine and pain offices about the shoulder criteria before ordering treatment.
Codes mentioned
28890E11.21I20.0I20.9I97.2F52.21F52.9G44.86G56.00G56.03G80.0G80.1G80.2I12.0I12.9I69.398I73.9J44.0J44.9L89.200L89.229L89.301L89.329L89.500L89.629L90.5L91.0L94.0L94.1L97.101L97.929L98.491L98.499M00.061M00.069M00.161M00.169M00.261M00.269M00.861M00.869M02.061M02.069M02.161M02.169M02.261M02.269M02.361M02.369M02.861M02.869M05.061M05.069M05.161M05.169M05.261M05.269M05.361M05.369M05.461M05.469M05.561M05.569M05.661M05.669M05.761M05.769M05.861M05.869M06.061M06.069M06.861M06.869M07.661M07.669M08.061M08.069M08.261M08.269M08.461M08.469M08.861M08.869M08.961M08.969M12.561M12.569M12.861M12.869M13.161M13.169M13.861M13.869M17.0M17.9M18.0M18.9M20.40M20.42M25.511M25.529M25.571M25.579M25.711M25.719M75.40M75.42M75.80M75.92M26.89M41.00M41.08M41.122M41.129M41.20M41.27M48.40XAM48.48XSM50.00M50.03M50.20M50.23M51.24M51.27M51.04M51.06M53.3M54.14M54.17M54.30M54.42M54.50M54.59M61.00M61.9M61.50M61.59M65.28M65.88M65.871M65.879M71.58M72.2M75.00M75.02M75.100M75.22M76.00M76.02M76.10M76.12M76.30M76.32M76.50M76.52M76.811M76.829M76.891M76.899M77.00M77.12M77.30M77.32M77.9M79.12M79.18M79.651M79.659M80.00XAM80.8AXSM84.30XAM84.759SM87.08M87.188M87.28M87.38M87.88M89.8X6M93.271M93.279M93.871M93.879M96.1
Original notice
Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries (CPB 0649, reviewed 2025-10-02)
aetna.com · Always check the source before changing claims.
Related changes
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Related policy hubs
Aetna policiesOrthopedicsSports MedicinePain ManagementPodiatryPhysical TherapyWound CareUrologyCardiologyNeurologyCode 28890Code E11.21Code I20.0Code I20.9Code I97.2Code F52.21Code F52.9Code G44.86Code G56.00Code G56.03Code G80.0Code G80.1Code G80.2Code I12.0Code I12.9Code I69.398Code I73.9Code J44.0Code J44.9Code L89.200Code L89.229Code L89.301Code L89.329Code L89.500Code L89.629Code L90.5Code L91.0Code L94.0Code L94.1Code L97.101Code L97.929Code L98.491Code L98.499Code M00.061Code M00.069Code M00.161Code M00.169Code M00.261Code M00.269Code M00.861Code M00.869Code M02.061Code M02.069Code M02.161Code M02.169Code M02.261Code M02.269Code M02.361Code M02.369Code M02.861Code M02.869Code M05.061Code M05.069Code M05.161Code M05.169Code M05.261Code M05.269Code M05.361Code M05.369Code M05.461Code M05.469Code M05.561Code M05.569Code M05.661Code M05.669Code M05.761Code M05.769Code M05.861Code M05.869Code M06.061Code M06.069Code M06.861Code M06.869Code M07.661Code M07.669Code M08.061Code M08.069Code M08.261Code M08.269Code M08.461Code M08.469Code M08.861Code M08.869Code M08.961Code M08.969Code M12.561Code M12.569Code M12.861Code M12.869Code M13.161Code M13.169Code M13.861Code M13.869Code M17.0Code M17.9Code M18.0Code M18.9Code M20.40Code M20.42Code M25.511Code M25.529Code M25.571Code M25.579Code M25.711Code M25.719Code M75.40Code M75.42Code M75.80Code M75.92Code M26.89Code M41.00Code M41.08Code M41.122Code M41.129Code M41.20Code M41.27Code M48.40XACode M48.48XSCode M50.00Code M50.03Code M50.20Code M50.23Code M51.24Code M51.27Code M51.04Code M51.06Code M53.3Code M54.14Code M54.17Code M54.30Code M54.42Code M54.50Code M54.59Code M61.00Code M61.9Code M61.50Code M61.59Code M65.28Code M65.88Code M65.871Code M65.879Code M71.58Code M72.2Code M75.00Code M75.02Code M75.100Code M75.22Code M76.00Code M76.02Code M76.10Code M76.12Code M76.30Code M76.32Code M76.50Code M76.52Code M76.811Code M76.829Code M76.891Code M76.899Code M77.00Code M77.12Code M77.30Code M77.32Code M77.9Code M79.12Code M79.18Code M79.651Code M79.659Code M80.00XACode M80.8AXSCode M84.30XACode M84.759SCode M87.08Code M87.188Code M87.28Code M87.38Code M87.88Code M89.8X6Code M93.271Code M93.279Code M93.871Code M93.879Code M96.1