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Coverage criteria policies

Bone stimulator, electronic and ultrasonic

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for a bone stimulator, electronic and ultrasonic.

Coverage

An electronic and ultrasonic bone stimulator is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Electrical Bone Stimulator, Noninvasive (E0747, E0748)

A noninvasive bone stimulator device is covered only for the following indications:

  1. Nonspinal bone stimulator (E0747 - osteogenesis stimulator, noninvasive, other than spinal applications) are covered for fractures that have a gap of less than 1cm or one-half the bone diameter, and:
    1. Show no progression toward healing based on radiographs taken at 1 month intervals for at least 3 months prior to the start of electrical treatments; or
    2. Have been surgically treated but fail to show evidence of union; or
    3. Nonunion of a fracture after 6 or more months have elapsed without healing of the fracture; or
    4. A fracture complicated by congenital pseudoarthrosis; or
    5. A documented failed fusion of a joint other than in the spine; or
    6. In conjunction with surgery, certain fractures associated with high-risk of nonunion will be covered on a case by case basis.
  2. Spinal bone stimulator (E0748 - osteogenesis stimulator, noninvasive, spinal application) is covered if any of the following criteria are met:
    1. Failed spinal fusion where a minimum of 9 months has elapsed since the last surgery; or
    2. Following a multilevel spinal fusion surgery. A multiple level fusion involves 3 or more vertebrae (e.g., L3-L5, L4-S1, etc.); or
    3. Following spinal surgery where there is a history of a previously failed spinal fusion.

Electrical Bone Stimulator, Invasive (E0749)

An invasive bone stimulator device is covered only for the following indications:

  1. Nonunion of long bone fracture; or
  2. As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed spinal fusion at the same site or for those undergoing multiple level fusion. A multiple level fusion involves 3 or more vertebrae (e.g., L3-L5, L4-S1, etc.).

Nonunion of a long bone fracture is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days.

Ultrasonic osteogenic stimulator (E0760)

Ultrasonic osteogenic bone stimulator device is covered as a treatment of nonunions of bones, when all the following criteria are met:

  1. The fracture is not of the skull or vertebrae or related to tumor and
  2. The fracture gap is one centimeter or less and
  3. A minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days. Each radiograph must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.

Ultrasonic bone stimulator is covered for the following types of fresh (7 days or less), in skeletally mature members at any of the following sites:

  1. Tibial diaphyesal or fibula fractures
  2. 5th metatarsal (Jones fracture)
  3. Scaphoid (carpal Navicular)

Indications that are not covered

  1. Not covered for any indications other than those described above due to insufficient supporting scientific literature.
  2. Bone growth stimulator is not covered for recipients who have any contraindication listed in the device’s package insert (e.g. recipients who are pregnant or nursing).
  3. The ultrasonic osteogenic stimulator may not be used concurrently with other non-invasive osteogenic devices.

Definitions

Electrical stimulation to augment bone repair can be attained either invasively or noninvasively. Invasive devices provide electrical stimulation directly at the fracture site either through percutaneously placed cathodes or by implantation of a coiled cathode wire into the fracture site. The power pack for the latter device is implanted into soft tissue near the fracture site and subcutaneously connected to the cathode, creating a self-contained system with no external components. The power supply for the former device is externally placed and the leads connected to the inserted cathodes. With the noninvasive device, opposing pads, wired to an external power supply, are placed over the cast. An electromagnetic field is created between the pads at the fracture site.

Ultrasonic osteogenic stimulator is a non-invasive device that emits low intensity, pulsed ultrasound. The ultrasound signal is applied to the skin surface at the fracture location via ultrasound, conductive gel in order to stimulate fracture healing.

Long Bone: The definition of "long bone" is limited to the following bones: clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpal, or metatarsal bones

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

E0747

Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

E0748

Osteogenesis stimulator, electrical, noninvasive, spinal applications

E0749

Osteogenesis stimulator, electrical, surgically implanted

E0760

Osteogenesis stimulator, low intensity ultrasound, noninvasive

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Aleem, I. S., Aleem, I., Evaniew, N., Busse, J.W., Yaszemski, M., Agarwal, A.,Einhorn, T., Bhandari, M. (2016).Efficacy of Electrical Stimulators for Bone Healing. Scientific Reports, 6: 31724. doi:10.1038/srep31724
  2. ECRI Institute. (2016). Electric Bone Growth Stimulating Devices for Treating Acute and Nonunion Bone Fractures. Plymouth Meeting, PA: ECRI Institute.
  3. , Hayes, Inc. Directory. Ultrasound Bone Growth Stimulation. Lansdale, PA: Hayes, Inc. September, 2015
  4. Hayes, Inc. Directory. Electrical Bone Growth Stimulation, Invasive. Lansdale, PA: Hayes, Inc. July, 2016
  5. Hayes, Inc. Directory. Noninvasive Electrical Bone Growth Stimulators for Acute, Delayed Union, and Nonunion Fractures. Philadelphia, PA: Hayes, Inc. 2016
  6. Santolini, Emmanuele, West, Robert, Giannoudisa,Peter V. (2015) Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence. Injury, Int. J. Care Injured 46 S8 S8–S19
  7. Streit, A., Watson, B. C., Granata, J. D., Philbin, T. M., Lin, H., OConnor, J. P., & Lin, S. (2016). Effect on clinical outcome and growth factor synthesis with adjunctive use of pulsed electromagnetic fields for fifth metatarsal nonunion fracture: A double-blind randomized study. Foot & Ankle International, 37(9), 919–923. doi:10.1177/1071100716652621

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Policy activity

  • 10/01/1997 - Date of origin
  • 03/01/2018 - Effective date
Review date
  • 10/2017
Revision date
  • 11/27/2017

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