I.  Low dose radiation therapy for the treatment osteoarthritis and plantar fasciitis is not medically necessary. 

Note:  This policy does not pertain to radiation therapy for cancer treatment. 

OA is the most common form of arthritis globally, affecting approximately 3.3-3.6% of the population worldwide and causing moderate to severe disability in 43 million people. It can be classified as primary (idiopathic) or secondary (due to a predisposing condition). Management includes non-pharmacologic approaches (e.g., exercise, weight loss) and pharmacologic interventions (e.g., acetaminophen, NSAIDs, intra-articular corticosteroid injections). For severe cases unresponsive to conservative measures, surgical options like joint replacement may be considered. OA is characterized by joint pain, stiffness, and locomotor restriction, but its presentation and progression vary greatly between individuals. Diagnosis is primarily clinical, based on symptoms and physical examination findings, with imaging studies used for confirmation and staging. The pathophysiology involves an interplay of risk factors, mechanical stress, and abnormal joint mechanics, leading to pro-inflammatory markers and proteases that mediate joint destruction. Management includes non-pharmacologic approaches (e.g., exercise, weight loss) and pharmacologic interventions (e.g., acetaminophen, NSAIDs, intra-articular corticosteroid injections). For severe cases unresponsive to conservative measures, surgical options like joint replacement may be considered. In some settings, LDRT has been explored as a treatment option for OA, typically involving the application of radiation to affected joints in multiple fractions over a short period.

Plantar fasciitis is a common cause of heel pain resulting from degenerative irritation of the plantar fascia and surrounding structures. It affects approximately 1 million patients annually in the United States, with peak incidence between ages of 40 to 60 years. Diagnosis is primarily clinical, based on localized heel pain that is worst with initial steps in the morning or after prolonged rest. While imaging is not typically needed for diagnosis, ultrasound may reveal thickening and heterogeneity of the plantar fascia. Treatment generally begins with conservative measures such as rest, NSAIDs, stretching exercises, orthotics, and night splints. For recalcitrant cases, more advanced therapies like extracorporeal shock wave therapy, botulinum toxin injections, platelet-rich plasma, prolotherapy, or corticosteroid injections have been considered. Surgery is reserved as a last resort for cases that fail to respond to at least 6-12 months of non-operative management. LDRT represents another alternative to surgical treatment for plantar fasciitis and typically involves the application of fractionated doses of radiation to the affected area. Total doses generally range from 3 to 6 Gy, delivered in fractions of 0.5 to 1 Gy, 2-3 times per week. The mechanism of action is thought to involve anti-inflammatory effects, including decreased expression of certain enzymes and reduction in the adhesion of peripheral blood mononuclear cells.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in 'Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

German Society of Radiation Oncology

While U.S.-based guidelines are typically prioritized when available, there are currently no such guidelines for low-dose radiation therapy (LDRT) in non-oncologic conditions. Much of the evidence for this approach originates from Germany, and The German Society of Radiation Oncology (DEGRO) guidelines reflect this body of experience. DEGRO published their Consensus Guideline on Radiation Therapy of Benign Diseases in 2015. DEGRO issued an update in 2018, but it was not translated to English. Recommendations pertaining to the indications in this review are as follows:

Osteoarthritis and Plantar Fasciitis:

• Because of general radiation protection considerations, radiotherapy should be recommended if non-radiotherapeutic approaches did not succeed.
• Patients < 40 years should be irradiated in very exceptional cases and after careful evaluation of the potential risk versus the expected benefit.
• Single doses of 0.5–1.0 Gy and total doses of 3.0–6.0 Gy/series with 2–3 fractions per week are recommended.
• Success rates for pain relief and freedom of pain should be assessed 2–3 months after radiotherapy because of delayed response effects.
• DEGRO provided the following recommendations by condition:
• Plantar fasciitis: Level of Evidence 1b (RCT evidence), Grade of Recommendation A (High-quality evidence)
• Gonarthrosis: Level of Evidence 2c (outcomes research or ecological studies), Grade of Recommendation B (Moderate-quality evidence)
• Coxarthrosis: Level of Evidence 4 (case series, poor quality cohort and case-control studies), Grade of Recommendation C (Low-quality evidence)
• Hand and finger joint arthrosis: Level of Evidence 4 (case series, poor quality cohort and case-control studies), Grade of Recommendation C (Low-quality evidence)