Extracorporeal shock wave therapy to lose insurance coverage beyond 12 sessions a year

The Financial Supervisory Service announced Wednesday that it will introduce dispute-resolution criteria for indemnity insurance claims related to extracorporeal shock wave therapy, effective July 1.

Extracorporeal shock wave therapy, along with manual therapy, is one of the most widely used non-covered treatments for musculoskeletal conditions. Concerns had been raised that once manual therapy is designated as "managed benefit" — with its price and frequency regulated starting July 1 — medical institutions might actively steer patients toward shock wave therapy instead, creating a balloon effect. In practice, cases involving 12 or more shock wave sessions accounted for just 4.6 percent of all indemnity insurance claims filed with non-life insurers last year, but treatment costs varied by as much as 300,000 won ($195) or more depending on the medical institution.

In response, the Korean Medical Association developed a voluntary management plan, including guidelines for extracorporeal shock wave therapy, following discussions with specialist medical societies. The Ministry of Health and Welfare convened a non-covered treatment management policy consultative body meeting on June 17 to discuss and announce the guidelines.

Based on those guidelines, the Financial Supervisory Service drew up dispute-resolution criteria for extracorporeal shock wave therapy and completed a review by its dispute-resolution subcommittee on Wednesday. The measures are intended to protect consumers from unnecessary or unclear treatments and to prevent leakage in indemnity insurance payouts.

The core of the dispute-resolution criteria is that treatment necessity will, in principle, be recognized only when all three conditions are met — eligible treatment targets, permissible treatment frequency and method, and prohibited treatment categories — and there are no signs of insurance fraud.

Eligible treatment targets are limited to conditions in seven body areas: the shoulder joint (calcific tendinitis and rotator cuff tendinopathy), the elbow joint (lateral epicondylitis and medial epicondylitis), the hip joint (greater trochanteric pain syndrome), the knee joint (patellar tendinitis), the ankle joint (Achilles tendinitis), the foot (plantar fasciitis), and the spine (cervical and lumbar myofascial pain syndrome).

Treatment frequency is capped at 12 sessions per year and six sessions per body area, at one session per week. The six-session limit applies by body area regardless of which side of the body is treated or the specific diagnosis, and when multiple areas are treated in a single visit, reimbursement covers only one area per visit. The annual count is calculated in one-year increments starting from the date of the first treatment on or after the guideline's effective date of July 1.

Prohibited treatment categories include cases with a tendency to bleed or a high bleeding risk due to anticoagulant therapy, tumors, infected tissue or pregnancy at the treatment site, acute fractures or ruptures, and lesions near the growth plates of patients under 18. However, the criteria allow for additional review of treatment necessity beyond the 12-session annual limit in special circumstances, such as when a serious illness causes complex conditions across multiple body areas.

The Financial Supervisory Service plans to post the key details of the dispute-resolution criteria on its website under the "Complaints and Reports — Dispute Resolution Information" menu. Insurance companies also plan to notify individual indemnity insurance policyholders via messaging services so that consumers have sufficient information to decide whether to seek treatment.