Criteria
Both invasive and noninvasive non-spinal electrical bone growth stimulation may be considered medically necessary in the treatment of a non-united fracture. A non-united fracture is defined as a fracture that has not healed within a minimum of three (3) months of the original fracture.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of nonunion fracture in the appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper extremities, pelvis and lower extremities). The diagnosis of fracture nonunion must meet
ALL
of the following criteria:
-
At least three (3) months have passed since the date of the fracture;
and
-
Serial radiographs have confirmed that no progressive signs of healing have occurred;
and
-
The fracture gap is one (1) centimeter or less;
and
- The individual can be adequately immobilized and is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of congenital pseudoarthrosis in the appendicular skeleton.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of failed fusion of the appendicular skeleton when a minimum of nine (9) months has elapsed since the last surgical intervention.
Non-spinal Electrical Bone Growth Stimulation (EBGS) not meeting the criteria as indicated in this policy is considered not medically necessary.
When the doctor reports electrical stimulation, the claim should be processed under the appropriate code for electrical stimulation. Use of the device is included in the doctor's global allowance for the electrical stimulation (i.e., no separate payment can be made for the device).
However, if the individual employs the stimulator at home, rental or purchase of the device may be eligible for payment. In this instance, any charges reported by the doctor for electrical stimulation should be denied as not medically necessary.
Procedure Codes
