Ultrasound Osteogenesis Stimulator

Policy ID: E-35-021

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: November 30, 2020

Revision Effective Date: January 04, 2021

Last Reviewed: November 19, 2020

Description

An ultrasonic osteogenesis stimulator is a noninvasive device that emits low intensity, pulsed ultrasound. The ultrasound signal is applied to the skin surface at the fracture location via ultrasound conductive coupling gel in order to stimulate fracture healing.

Criteria

An ultrasonic osteogenesis stimulator may be considered medically necessary if ALL of the following criteria are met:

Nonunion of a fracture (at least three (3) months have passed since the date of the fracture); and
The fracture is not of the skull or vertebrae; and
Serial radiographs have confirmed that no progressive signs of healing have occurred; and
The fracture gap is one (1) cm or less; and
The individual can be adequately immobilized and is able to maintain a non-weight bearing status.

Fresh Closed Fractures

An individual who has been determined to be at high risk for delayed fracture healing or nonunion fractures, includes at least ONE of the following indications:

Comorbidity:

The individual hasANYof the following comorbidities:

- Diagnosis of alcoholism; or
- Current tobacco use; or
- Diagnosis of diabetes; or
- Current use of prescribed steroid; or
- Diagnosis of osteoporosis; or
- Diagnosis of renal disease; or
- Current use of prescribed anticoagulation medications.

Location of fracture:
- Fracture of metatarsal, including Jones fracture (5th metatarsal); or
- Navicular bone fracture of the wrist (also known as the scaphoid); or
- Fractures associated with extensive soft tissue or vascular damage.

If the above criteria are not met, an ultrasonic osteogenesis stimulator will be denied as not medically necessary. This includes, but is not limited to treatment of ANY of the following:

As an adjunct to (i.e., at the time of or immediately after) bunionectomy procedures (When such surgery results in nonunion the medically necessary criteria above may apply); or
As an adjunct to (i.e., at the time of or immediately after) distraction osteogenesis procedures for any indication (e.g., limb lengthening, nonunion, or tibial defects); or
Axial skeleton fractures, including the skull and vertebrae; or
Congenital pseudoarthrosis; or
Delayed fracture unions without a comorbidity; or
Fresh fractures that are Open Grade II or III, or require surgical intervention (with or without internal fixation), or are otherwise too unstable for closed reduction/; or
Patellar tendinopathy; or
Pathological fractures due to bone pathology or tumor/malignancy; or
Stress fractures;or
Used with other nonivasive osteogenesis stimulators.

Procedure Codes

20979

A4559

E0760

An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other noninvasive osteogenesis stimulators.

Procedure Codes

E0747

E0760

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 20979, A4559 and E0760

E10.65	E10.9	E11.65	E11.9	E13.9	F10.20	F17.200
F17.201	F17.210	F17.211	F17.220	F17.221	F17.290	F17.291
M80.0AXG	M80.0AXK	M80.00XK	M80.011K	M80.012K	M80.021K	M80.022K
M80.031K	M80.032K	M80.041K	M80.042K	M80.051K	M80.052K	M80.061K
M80.062K	M80.071K	M80.072K	M80.8AXG	M80.8AXK	M80.80XK	M80.811K
M80.812K	M80.821K	M80.822K	M80.831K	M80.832K	M80.841K	M80.842K
M80.851K	M80.852K	M80.861K	M80.862K	M80.871K	M80.872K	M81.6
M84.40XK	M84.411K	M84.412K	M84.421K	M84.422K	M84.431K	M84.432K
M84.433K	M84.434K	M84.441K	M84.442K	M84.444K	M84.445K	M84.451K
M84.452K	M84.454K	M84.459K	M84.461K	M84.462K	M84.463K	M84.464K
M84.471K	M84.472K	M84.474K	M84.475K	M84.477K	M84.478K	M84.48XK
M84.60XK	M84.611K	M84.612K	M84.621K	M84.622K	M84.631K	M84.632K
M84.633K	M84.634K	M84.641K	M84.642K	M84.650K	M84.651K	M84.652K
M84.659K	M84.661K	M84.662K	M84.663K	M84.664K	M84.671K	M84.672K
M84.674K	M84.675K	M84.750G	M84.750K	M84.754G	M84.754K	M84.757G
M84.755G	M84.755K	M84.756G	M84.756K	M84.757K	M84.758G	M84.758K
M84.759G	M84.759K	N18.1	N18.2	N18.30	N18.31	N18.32
N18.4	N18.5	N18.6	N18.9	S22.20XK	S22.21XK	S22.22XK
S22.23XK	S22.24XK	S22.31XK	S22.32XK	S22.39XK	S22.41XK	S22.42XK
S22.43XK	S22.49XK	S22.5XXK	S22.9XXK	S32.301K	S32.302K	S32.311K
S32.312K	S32.314K	S32.315K	S32.391K	S32.392K	S32.401K	S32.402K
S32.411K	S32.412K	S32.414K	S32.415K	S32.421K	S32.422K	S32.424K
S32.425K	S32.431K	S32.432K	S32.434K	S32.435K	S32.441K	S32.442K
S32.444K	S32.445K	S32.451K	S32.452K	S32.454K	S32.455K	S32.461K
S32.462K	S32.464K	S32.465K	S32.471K	S32.472K	S32.474K	S32.475K
S32.481K	S32.482K	S32.484K	S32.485K	S32.491K	S32.492K	S32.501K
S32.502K	S32.511K	S32.512K	S32.591K	S32.592K	S32.601K	S32.602K
S32.611K	S32.612K	S32.614K	S32.615K	S32.691K	S32.692K	S32.810K
S32.811K	S42.001K	S42.002K	S42.011K	S42.012K	S42.014K	S42.015K
S42.017K	S42.018K	S42.021K	S42.022K	S42.024K	S42.025K	S42.031K
S42.032K	S42.034K	S42.035K	S42.101K	S42.102K	S42.111K	S42.112K
S42.114K	S42.115K	S42.121K	S42.122K	S42.124K	S42.125K	S42.131K
S42.132K	S42.134K	S42.135K	S42.141K	S42.142K	S42.144K	S42.145K
S42.151K	S42.152K	S42.154K	S42.155K	S42.191K	S42.192K	S42.201K
S42.202K	S42.211K	S42.212K	S42.214K	S42.215K	S42.221K	S42.222K
S42.224K	S42.225K	S42.231K	S42.232K	S42.241K	S42.242K	S42.251K
S42.252K	S42.254K	S42.255K	S42.261K	S42.262K	S42.264K	S42.265K
S42.271K	S42.272K	S42.291K	S42.292K	S42.294K	S42.295K	S42.301K
S42.302K	S42.311K	S42.312K	S42.321K	S42.322K	S42.324K	S42.325K
S42.331K	S42.332K	S42.334K	S42.335K	S42.341K	S42.342K	S42.344K
S42.345K	S42.351K	S42.352K	S42.354K	S42.355K	S42.361K	S42.362K
S42.364K	S42.365K	S42.391K	S42.392K	S42.401K	S42.402K	S42.411K
S42.412K	S42.414K	S42.415K	S42.421K	S42.422K	S42.424K	S42.425K
S42.431K	S42.432K	S42.434K	S42.435K	S42.441K	S42.442K	S42.444K
S42.445K	S42.447K	S42.448K	S42.451K	S42.452K	S42.454K	S42.455K
S42.461K	S42.462K	S42.464K	S42.465K	S42.471K	S42.472K	S42.474K
S42.475K	S42.481K	S42.482K	S42.491K	S42.492K	S42.494K	S42.495K
S42.91XK	S42.92XK	S49.001K	S49.002K	S49.011K	S49.012K	S49.021K
S49.022K	S49.031K	S49.032K	S49.041K	S49.042K	S49.091K	S49.092K
S49.101K	S49.102K	S49.111K	S49.112K	S49.121K	S49.122K	S49.131K
S49.132K	S49.141K	S49.142K	S49.191K	S49.192K	S52.001K	S52.001M
S52.001N	S52.002K	S52.002M	S52.002N	S52.011K	S52.012K	S52.021K
S52.021M	S52.021N	S52.022K	S52.022M	S52.022N	S52.024K	S52.024M
S52.024N	S52.025K	S52.025M	S52.025N	S52.031K	S52.031M	S52.031N
S52.032K	S52.032M	S52.032N	S52.034K	S52.034M	S52.034N	S52.035K
S52.035M	S52.035N	S52.041K	S52.041M	S52.041N	S52.042K	S52.042M
S52.042N	S52.044K	S52.044M	S52.044N	S52.045K	S52.045M	S52.045N
S52.091K	S52.091M	S52.091N	S52.092K	S52.092M	S52.092N	S52.101K
S52.101M	S52.101N	S52.102K	S52.102M	S52.102N	S52.111K	S52.112K
S52.121K	S52.121M	S52.121N	S52.122K	S52.122M	S52.122N	S52.124K
S52.124M	S52.124N	S52.125K	S52.125M	S52.125N	S52.131K	S52.131M
S52.131N	S52.132K	S52.132M	S52.132N	S52.134K	S52.134M	S52.134N
S52.135K	S52.135M	S52.135N	S52.181K	S52.181M	S52.181N	S52.182K
S52.182M	S52.182N	S52.201K	S52.201M	S52.201N	S52.202K	S52.202M
S52.202N	S52.211K	S52.212K	S52.221K	S52.221M	S52.221N	S52.222K
S52.222M	S52.222N	S52.224K	S52.224M	S52.224N	S52.225K	S52.225M
S52.225N	S52.231K	S52.231M	S52.231N	S52.232K	S52.232M	S52.232N
S52.234K	S52.234M	S52.234N	S52.235K	S52.235M	S52.235N	S52.241K
S52.241M	S52.241N	S52.242K	S52.242M	S52.242N	S52.244K	S52.244M
S52.244N	S52.245K	S52.245M	S52.245N	S52.251K	S52.251M	S52.251N
S52.252K	S52.252M	S52.252N	S52.254K	S52.254M	S52.254N	S52.255K
S52.255M	S52.255N	S52.261K	S52.261M	S52.261N	S52.262K	S52.262M
S52.262N	S52.264K	S52.264M	S52.264N	S52.265K	S52.265M	S52.265N
S52.271K	S52.271M	S52.271N	S52.272K	S52.272M	S52.272N	S52.281K
S52.281M	S52.281N	S52.282K	S52.282M	S52.282N	S52.291K	S52.291M
S52.291N	S52.292K	S52.292M	S52.292N	S52.301K	S52.301M	S52.301N
S52.302K	S52.302M	S52.302N	S52.311K	S52.312K	S52.321K	S52.321M
S52.321N	S52.322K	S52.322M	S52.322N	S52.324K	S52.324M	S52.324N
S52.325K	S52.325M	S52.325N	S52.331K	S52.331M	S52.331N	S52.332K
S52.332M	S52.332N	S52.334K	S52.334M	S52.334N	S52.335K	S52.335M
S52.335N	S52.341K	S52.341M	S52.341N	S52.342K	S52.342M	S52.342N
S52.344K	S52.344M	S52.344N	S52.345K	S52.345M	S52.345N	S52.351K
S52.351M	S52.351N	S52.352K	S52.352M	S52.352N	S52.354K	S52.354M
S52.354N	S52.355K	S52.355M	S52.355N	S52.361K	S52.361M	S52.361N
S52.362K	S52.362M	S52.362N	S52.364K	S52.364M	S52.364N	S52.365K
S52.365M	S52.365N	S52.371K	S52.371M	S52.371N	S52.372K	S52.372M
S52.372N	S52.381K	S52.381M	S52.381N	S52.382K	S52.382M	S52.382N
S52.391K	S52.391M	S52.391N	S52.392K	S52.392M	S52.392N	S52.501K
S52.501M	S52.501N	S52.502K	S52.502M	S52.502N	S52.511K	S52.511M
S52.511N	S52.512K	S52.512M	S52.512N	S52.514K	S52.514M	S52.514N
S52.515K	S52.515M	S52.515N	S52.521K	S52.522K	S52.531K	S52.531M
S52.531N	S52.532K	S52.532M	S52.532N	S52.541K	S52.541M	S52.541N
S52.542K	S52.542M	S52.542N	S52.551K	S52.551M	S52.551N	S52.552K
S52.552M	S52.552N	S52.561K	S52.561M	S52.561N	S52.562K	S52.562M
S52.562N	S52.571K	S52.571M	S52.571N	S52.572K	S52.572M	S52.572N
S52.591K	S52.591M	S52.591N	S52.592K	S52.592M	S52.592N	S52.601K
S52.601M	S52.601N	S52.602K	S52.602M	S52.602N	S52.611K	S52.611M
S52.611N	S52.612K	S52.612M	S52.612N	S52.614K	S52.614M	S52.614N
S52.615K	S52.615M	S52.615N	S52.621K	S52.622K	S52.691K	S52.691M
S52.691N	S52.692K	S52.692M	S52.692N	S52.90XK	S52.90XM	S52.90XN
S52.91XK	S52.91XM	S52.91XN	S52.92XK	S52.92XM	S52.92XN	S59.001K
S59.002K	S59.011K	S59.012K	S59.021K	S59.022K	S59.031K	S59.032K
S59.041K	S59.042K	S59.091K	S59.092K	S59.101K	S59.102K	S59.111K
S59.112K	S59.121K	S59.122K	S59.131K	S59.132K	S59.141K	S59.142K
S59.191K	S59.192K	S59.201K	S59.202K	S59.211K	S59.212K	S59.221K
S59.222K	S59.231K	S59.232K	S59.241K	S59.242K	S59.291K	S59.292K
S62.001A	S62.001K	S62.002A	S62.002K	S62.011A	S62.011K	S62.012A
S62.012K	S62.014A	S62.014K	S62.015A	S62.015K	S62.021A	S62.021K
S62.022A	S62.022K	S62.024A	S62.024K	S62.025A	S62.025K	S62.031A
S62.031K	S62.032A	S62.032K	S62.034A	S62.034K	S62.035A	S62.035K
S62.101K	S62.102K	S62.111K	S62.112K	S62.114K	S62.115K	S62.121K
S62.122K	S62.124K	S62.125K	S62.131K	S62.132K	S62.134K	S62.135K
S62.141K	S62.142K	S62.144K	S62.145K	S62.151K	S62.152K	S62.154K
S62.155K	S62.161K	S62.162K	S62.164K	S62.165K	S62.171K	S62.172K
S62.174K	S62.175K	S62.181K	S62.182K	S62.184K	S62.185K	S62.201K
S62.202K	S62.211K	S62.212K	S62.221K	S62.222K	S62.224K	S62.225K
S62.231K	S62.232K	S62.234K	S62.235K	S62.241K	S62.242K	S62.244K
S62.245K	S62.251K	S62.252K	S62.254K	S62.255K	S62.291K	S62.292K
S62.300K	S62.301K	S62.302K	S62.303K	S62.304K	S62.305K	S62.306K
S62.307K	S62.310K	S62.311K	S62.312K	S62.313K	S62.314K	S62.315K
S62.316K	S62.317K	S62.320K	S62.321K	S62.322K	S62.323K	S62.324K
S62.325K	S62.326K	S62.327K	S62.330K	S62.331K	S62.332K	S62.333K
S62.334K	S62.335K	S62.336K	S62.337K	S62.340K	S62.341K	S62.342K
S62.343K	S62.344K	S62.345K	S62.346K	S62.347K	S62.348K	S62.349K
S62.350K	S62.351K	S62.352K	S62.353K	S62.354K	S62.355K	S62.356K
S62.357K	S62.360K	S62.361K	S62.362K	S62.363K	S62.364K	S62.365K
S62.366K	S62.367K	S62.390K	S62.391K	S62.392K	S62.393K	S62.394K
S62.395K	S62.396K	S62.397K	S62.501K	S62.502K	S62.511K	S62.512K
S62.514K	S62.515K	S62.521K	S62.522K	S62.524K	S62.525K	S62.600K
S62.601K	S62.602K	S62.603K	S62.604K	S62.605K	S62.606K	S62.607K
S62.610K	S62.611K	S62.612K	S62.613K	S62.614K	S62.615K	S62.616K
S62.617K	S62.620K	S62.621K	S62.622K	S62.623K	S62.624K	S62.625K
S62.626K	S62.627K	S62.630K	S62.631K	S62.632K	S62.633K	S62.634K
S62.635K	S62.636K	S62.637K	S62.640K	S62.641K	S62.642K	S62.643K
S62.644K	S62.645K	S62.646K	S62.647K	S62.650K	S62.651K	S62.652K
S62.653K	S62.654K	S62.655K	S62.656K	S62.657K	S62.660K	S62.661K
S62.662K	S62.663K	S62.664K	S62.665K	S62.666K	S62.667K	S62.91XK
S62.92XK	S72.001K	S72.001M	S72.001N	S72.002K	S72.002M	S72.002N
S72.011K	S72.011M	S72.011N	S72.012K	S72.012M	S72.012N	S72.021K
S72.021M	S72.021N	S72.022K	S72.022M	S72.022N	S72.024K	S72.024M
S72.024N	S72.025K	S72.025M	S72.025N	S72.031K	S72.031M	S72.031N
S72.032K	S72.032M	S72.032N	S72.034K	S72.034M	S72.034N	S72.035K
S72.035M	S72.035N	S72.041K	S72.041M	S72.041N	S72.042K	S72.042M
S72.042N	S72.044K	S72.044M	S72.044N	S72.045K	S72.045M	S72.045N
S72.051K	S72.051M	S72.051N	S72.052K	S72.052M	S72.052N	S72.061K
S72.061M	S72.061N	S72.062K	S72.062M	S72.062N	S72.064K	S72.064M
S72.064N	S72.065K	S72.065M	S72.065N	S72.091K	S72.091M	S72.091N
S72.092K	S72.092M	S72.092N	S72.101K	S72.101M	S72.101N	S72.102K
S72.102M	S72.102N	S72.111K	S72.111M	S72.111N	S72.112K	S72.112M
S72.112N	S72.114K	S72.114M	S72.114N	S72.115K	S72.115M	S72.115N
S72.121K	S72.121M	S72.121N	S72.122K	S72.122M	S72.122N	S72.124K
S72.124M	S72.124N	S72.125K	S72.125M	S72.125N	S72.131K	S72.131M
S72.131N	S72.132K	S72.132M	S72.132N	S72.134K	S72.134M	S72.134N
S72.135K	S72.135M	S72.135N	S72.141K	S72.141M	S72.141N	S72.142K
S72.142M	S72.142N	S72.144K	S72.144M	S72.144N	S72.145K	S72.145M
S72.145N	S72.21XK	S72.21XM	S72.21XN	S72.22XK	S72.22XM	S72.22XN
S72.24XK	S72.24XM	S72.24XN	S72.25XK	S72.25XM	S72.25XN	S72.301K
S72.301M	S72.301N	S72.302K	S72.302M	S72.302N	S72.321K	S72.321M
S72.321N	S72.322K	S72.322M	S72.322N	S72.324K	S72.324M	S72.324N
S72.325K	S72.325M	S72.325N	S72.331K	S72.331M	S72.331N	S72.332K
S72.332M	S72.332N	S72.334K	S72.334M	S72.334N	S72.335K	S72.335M
S72.335N	S72.341K	S72.341M	S72.341N	S72.342K	S72.342M	S72.342N
S72.344K	S72.344M	S72.344N	S72.345K	S72.345M	S72.345N	S72.351K
S72.351M	S72.351N	S72.352K	S72.352M	S72.352N	S72.354K	S72.354M
S72.354N	S72.355K	S72.355M	S72.355N	S72.361K	S72.361M	S72.361N
S72.362K	S72.362M	S72.362N	S72.364K	S72.364M	S72.364N	S72.365K
S72.365M	S72.365N	S72.391K	S72.391M	S72.391N	S72.392K	S72.392M
S72.392N	S72.401K	S72.401M	S72.401N	S72.402K	S72.402M	S72.402N
S72.411K	S72.411M	S72.411N	S72.412K	S72.412M	S72.412N	S72.414K
S72.414M	S72.414N	S72.415K	S72.415M	S72.415N	S72.421K	S72.421M
S72.421N	S72.422K	S72.422M	S72.422N	S72.424K	S72.424M	S72.424N
S72.425K	S72.425M	S72.425N	S72.431K	S72.431M	S72.431N	S72.432K
S72.432M	S72.432N	S72.434K	S72.434M	S72.434N	S72.435K	S72.435M
S72.435N	S72.441K	S72.441M	S72.441N	S72.442K	S72.442M	S72.442N
S72.444K	S72.444M	S72.444N	S72.445K	S72.445M	S72.445N	S72.451K
S72.451M	S72.451N	S72.452K	S72.452M	S72.452N	S72.454K	S72.454M
S72.454N	S72.455K	S72.455M	S72.455N	S72.461K	S72.461M	S72.461N
S72.462K	S72.462M	S72.462N	S72.464K	S72.464M	S72.464N	S72.465K
S72.465M	S72.465N	S72.471K	S72.472K	S72.491K	S72.491M	S72.491N
S72.492K	S72.492M	S72.492N	S72.8X1K	S72.8X1M	S72.8X1N	S72.8X2K
S72.8X2M	S72.8X2N	S72.8X9K	S72.8X9M	S72.8X9N	S72.91XK	S72.91XM
S72.91XN	S72.92XK	S72.92XM	S72.92XN	S79.001K	S79.002K	S79.011K
S79.012K	S79.091K	S79.092K	S79.101K	S79.102K	S79.111K	S79.112K
S79.121K	S79.122K	S79.131K	S79.132K	S79.141K	S79.142K	S79.191K
S79.192K	S82.001K	S82.001M	S82.001N	S82.002K	S82.002M	S82.002N
S82.011K	S82.011M	S82.011N	S82.012K	S82.012M	S82.012N	S82.014K
S82.014M	S82.014N	S82.015K	S82.015M	S82.015N	S82.021K	S82.021M
S82.021N	S82.022K	S82.022M	S82.022N	S82.024K	S82.024M	S82.024N
S82.025K	S82.025M	S82.025N	S82.031K	S82.031M	S82.031N	S82.032K
S82.032M	S82.032N	S82.034K	S82.034M	S82.034N	S82.035K	S82.035M
S82.035N	S82.041K	S82.041M	S82.041N	S82.042K	S82.042M	S82.042N
S82.044K	S82.044M	S82.044N	S82.045K	S82.045M	S82.045N	S82.091K
S82.091M	S82.091N	S82.092K	S82.092M	S82.092N	S82.101K	S82.101M
S82.101N	S82.102K	S82.102M	S82.102N	S82.111K	S82.111M	S82.111N
S82.112K	S82.112M	S82.112N	S82.114K	S82.114M	S82.114N	S82.115K
S82.115M	S82.115N	S82.121K	S82.121M	S82.121N	S82.122K	S82.122M
S82.122N	S82.124K	S82.124M	S82.124N	S82.125K	S82.125M	S82.125N
S82.131K	S82.131M	S82.131N	S82.132K	S82.132M	S82.132N	S82.134K
S82.134M	S82.134N	S82.135K	S82.135M	S82.135N	S82.141K	S82.141M
S82.141N	S82.142K	S82.142M	S82.142N	S82.144K	S82.144M	S82.144N
S82.145K	S82.145M	S82.145N	S82.151K	S82.151M	S82.151N	S82.152K
S82.152M	S82.152N	S82.154K	S82.154M	S82.154N	S82.155K	S82.155M
S82.155N	S82.161K	S82.162K	S82.191K	S82.191M	S82.191N	S82.192K
S82.192M	S82.192N	S82.201K	S82.201M	S82.201N	S82.202K	S82.202M
S82.202N	S82.221K	S82.221M	S82.221N	S82.222K	S82.222M	S82.222N
S82.224K	S82.224M	S82.224N	S82.225K	S82.225M	S82.225N	S82.231K
S82.231M	S82.231N	S82.232K	S82.232M	S82.232N	S82.234K	S82.234M
S82.234N	S82.235K	S82.235M	S82.235N	S82.241K	S82.241M	S82.241N
S82.242K	S82.242M	S82.242N	S82.244K	S82.244M	S82.244N	S82.245K
S82.245M	S82.245N	S82.251K	S82.251M	S82.251N	S82.252K	S82.252M
S82.252N	S82.254K	S82.254M	S82.254N	S82.255K	S82.255M	S82.255N
S82.261K	S82.261M	S82.261N	S82.262K	S82.262M	S82.262N	S82.264K
S82.264M	S82.264N	S82.265K	S82.265M	S82.265N	S82.291K	S82.291M
S82.291N	S82.292K	S82.292M	S82.292N	S82.301K	S82.301M	S82.301N
S82.302K	S82.302M	S82.302N	S82.311K	S82.312K	S82.391K	S82.391M
S82.391N	S82.392K	S82.392M	S82.392N	S82.401K	S82.401M	S82.401N
S82.402K	S82.402M	S82.402N	S82.421K	S82.421M	S82.421N	S82.422K
S82.422M	S82.422N	S82.424K	S82.424M	S82.424N	S82.425K	S82.425M
S82.425N	S82.431K	S82.431M	S82.431N	S82.432K	S82.432M	S82.432N
S82.434K	S82.434M	S82.434N	S82.435K	S82.435M	S82.435N	S82.441K
S82.441M	S82.441N	S82.442K	S82.442M	S82.442N	S82.444K	S82.444M
S82.444N	S82.445K	S82.445M	S82.445N	S82.451K	S82.451M	S82.451N
S82.452K	S82.452M	S82.452N	S82.454K	S82.454M	S82.454N	S82.455K
S82.455M	S82.455N	S82.461K	S82.461M	S82.461N	S82.462K	S82.462M
S82.462N	S82.464K	S82.464M	S82.464N	S82.465K	S82.465M	S82.465N
S82.491K	S82.491M	S82.491N	S82.492K	S82.492M	S82.492N	S82.51XK
S82.51XM	S82.51XN	S82.52XK	S82.52XM	S82.52XN	S82.54XK	S82.54XM
S82.54XN	S82.55XK	S82.55XM	S82.55XN	S82.61XK	S82.61XM	S82.61XN
S82.62XK	S82.62XM	S82.62XN	S82.64XK	S82.64XM	S82.64XN	S82.65XK
S82.65XM	S82.65XN	S82.811K	S82.812K	S82.821K	S82.822K	S82.831K
S82.831M	S82.831N	S82.832K	S82.832M	S82.832N	S82.841K	S82.841M
S82.841N	S82.842K	S82.842M	S82.842N	S82.844K	S82.844M	S82.844N
S82.845K	S82.845M	S82.845N	S82.851K	S82.851M	S82.851N	S82.852K
S82.852M	S82.852N	S82.854K	S82.854M	S82.854N	S82.855K	S82.855M
S82.855N	S82.861K	S82.861M	S82.861N	S82.862K	S82.862M	S82.862N
S82.864K	S82.864M	S82.864N	S82.865K	S82.865M	S82.865N	S82.871K
S82.871M	S82.871N	S82.872K	S82.872M	S82.872N	S82.874K	S82.874M
S82.874N	S82.875K	S82.875M	S82.875N	S82.891K	S82.891M	S82.891N
S82.892K	S82.892M	S82.892N	S82.91XK	S82.91XM	S82.91XN	S82.92XK
S82.92XM	S82.92XN	S89.001K	S89.002K	S89.011K	S89.012K	S89.021K
S89.022K	S89.031K	S89.032K	S89.041K	S89.042K	S89.091K	S89.092K
S89.101K	S89.102K	S89.111K	S89.112K	S89.121K	S89.122K	S89.131K
S89.132K	S89.141K	S89.142K	S89.191K	S89.192K	S89.201K	S89.202K
S89.211K	S89.212K	S89.221K	S89.222K	S89.291K	S89.292K	S89.301K
S89.302K	S89.311K	S89.312K	S89.321K	S89.322K	S89.391K	S89.392K
S92.001K	S92.002K	S92.011K	S92.012K	S92.014K	S92.015K	S92.021K
S92.022K	S92.024K	S92.025K	S92.031K	S92.032K	S92.034K	S92.035K
S92.041K	S92.042K	S92.044K	S92.045K	S92.051K	S92.052K	S92.054K
S92.055K	S92.061K	S92.062K	S92.064K	S92.065K	S92.101K	S92.102K
S92.111K	S92.112K	S92.114K	S92.115K	S92.121K	S92.122K	S92.124K
S92.125K	S92.131K	S92.132K	S92.134K	S92.135K	S92.141K	S92.142K
S92.144K	S92.145K	S92.151K	S92.152K	S92.154K	S92.155K	S92.191K
S92.192K	S92.201K	S92.202K	S92.211K	S92.212K	S92.214K	S92.215K
S92.221K	S92.222K	S92.224K	S92.225K	S92.231K	S92.232K	S92.234K
S92.235K	S92.241K	S92.242K	S92.244K	S92.245K	S92.251K	S92.252K
S92.254K	S92.255K	S92.301A	S92.301K	S92.302A	S92.302K	S92.311K
S92.312K	S92.313A	S92.313K	S92.314A	S92.314K	S92.315A	S92.315K
S92.321A	S92.321K	S92.322A	S92.322K	S92.324A	S92.324K	S92.325A
S92.325K	S92.331A	S92.331K	S92.332A	S92.332K	S92.334A	S92.334K
S92.335A	S92.335K	S92.341A	S92.341K	S92.342A	S92.342K	S92.344A
S92.344K	S92.345A	S92.345K	S92.351A	S92.351K	S92.352A	S92.352K
S92.354A	S92.354K	S92.355A	S92.355K	S92.401K	S92.402K	S92.404K
S92.405K	S92.411K	S92.412K	S92.414K	S92.415K	S92.421K	S92.422K
S92.424K	S92.425K	S92.491K	S92.492K	S92.501K	S92.502K	S92.504K
S92.505K	S92.511K	S92.512K	S92.514K	S92.515K	S92.521K	S92.522K
S92.524K	S92.525K	S92.531K	S92.532K	S92.534K	S92.535K	S92.591K
S92.592K	S92.901K	S92.902K	S92.911K	S92.912K	S92.919K	Z92.240
Z92.241

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 no change to criteria, some diagnosis updates; updated to v. 19.

Internal Medical Policy Committee 11-19-2020 Removed the following diagnosis codes:

M84.30XK, M84.311K, M84.312K, M84.321K, M84.322K, M84.331K, M84.332K, M84.333K, M84.334K, M84.341K, M84.342K, M84.344K, M84.345K, M84350K, M84.351K, M84.352K, M84.359K, M84.361K, M84.362K, M84.363K, M84.364K, M84.371K, M84.372K, M84.374K, M84.375K, M84.377K, M84.378K, M84.38XK, M84.50XK, M84.511K, M84.512K, M84.521K, M84.522K, M84.531K, M84.532K, M84.533K, M84.534K, M84.541K, M84.542K, M84.550K, M84.551K, M84.552K, M84.559K, M84.561K, M84.562K, M84.563K, M84.564K, M84.571K, M84.572K, M84.574K, M84.575K, M84.58XK, M84.68XK

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: November 14, 2019

Last Reviewed: November 14, 2019

Archived Date: January 03, 2021

Description

Criteria

An ultrasonic osteogenesis stimulator is covered only if ALL of the following criteria are met:

Nonunion of a fracture (at least three (3) months have passed since the date of the fracture); and
The fracture is not of the skull or vertebrae; and
Serial radiographs have confirmed that no progressive signs of healing have occurred; and
The fracture gap is 1 cm or less; and
The patient can be adequately immobilized and is able to maintain a non-weight bearing status

Fresh Closed Fractures

Low-intensity ultrasound accelerated fracture healing systems may be considered medically necessary as an adjunct to conventional management (i.e., closed reduction and cast immobilization) for the treatment of fresh (up to fourteen (14) days after the fracture occurs), closed fractures of a skeletally mature individual, who is determined to be at high risk for delayed fracture healing or nonunion fractures, that includes having at least ONE of the following indications: a comorbidity OR location of fracture:

The individual has ANY of the following comorbidities:

Diagnosis of alcoholism; or
Current tobacco use; or
Diagnosis of diabetes; or
Current use of prescribed steroid; or
Diagnosis of osteoporosis; or
Diagnosis of renal disease; or
Current use of prescribed anticoagulation medications.
OR

The individual has ANY of the following fracture locations:

Fracture of metatarsal, including Jones fracture (5th metatarsal); or
Navicular bone fracture of the wrist (also known as the scaphoid); or
Fractures associated with extensive soft tissue or vascular damage.

It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in these situations.

If the above criteria are not met, an ultrasonic osteogenesis stimulator will be denied as not medically necessary. This includes, but is not limited to treatment of ANY of the following:

As an adjunct to (i.e., at the time of or immediately after) bunionectomy procedures (When such surgery results in nonunion the medically necessary criteria above may apply); or
As an adjunct to (i.e., at the time of or immediately after) distraction osteogenesis procedures for any indication (e.g., limb lengthening, nonunion, or tibial defects); or
Axial skeleton fractures, including the skull and vertebrae; or
Congenital pseudoarthrosis; or
Delayed fracture unions; or
Fresh fractures that are Open Grade II or III, or require surgical intervention (with or without internal fixation), or are otherwise too unstable for closed reduction/; or
Patellar tendinopathy; or
Pathological fractures due to bone pathology or tumor/malignancy; or
Stress fractures; or
Used with other nonivasive osteogenesis stimulators.

Procedure Codes

E0760

An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other noninvasive osteogenesis stimulators.

Procedure Codes

E0747

E0760

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 20979 and E0760

E10.9	E10.65	E11.65	E11.9	E13.9	F10.20	F17.200
F17.201	F17.210	F17.211	F17.220	F17.221	F17.290	F17.291
M80.00XK	M80.011K	M80.012K	M80.021K	M80.022K	M80.031K	M80.032K
M80.041K	M80.042K	M80.051K	M80.052K	M80.061K	M80.062K	M80.071K
M80.072K	M80.80XK	M80.811K	M80.812K	M80.821K	M80.822K	M80.831K
M80.832K	M80.841K	M80.842K	M80.851K	M80.852K	M80.861K	M80.862K
M80.871K	M80.872K	M81.6	M84.30XK	M84.311K	M84.312K	M84.321K
M84.322K	M84.331K	M84.332K	M84.333K	M84.334K	M84.341K	M84.342K
M84.344K	M84.345K	M84.350K	M84.351K	M84.352K	M84.359K	M84.361K
M84.362K	M84.363K	M84.364K	M84.371K	M84.372K	M84.374K	M84.375K
M84.377K	M84.378K	M84.38XK	M84.40XK	M84.411K	M84.412K	M84.421K
M84.422K	M84.431K	M84.432K	M84.433K	M84.434K	M84.441K	M84.442K
M84.444K	M84.445K	M84.451K	M84.452K	M84.454K	M84.459K	M84.461K
M84.462K	M84.463K	M84.464K	M84.471K	M84.472K	M84.474K	M84.475K
M84.477K	M84.478K	M84.48XK	M84.50XK	M84.511K	M84.512K	M84.521K
M84.522K	M84.531K	M84.532K	M84.533K	M84.534K	M84.541K	M84.542K
M84.550K	M84.551K	M84.552K	M84.559K	M84.561K	M84.562K	M84.563K
M84.564K	M84.571K	M84.572K	M84.574K	M84.575K	M84.58XK	M84.60XK
M84.611K	M84.612K	M84.621K	M84.622K	M84.631K	M84.632K	M84.633K
M84.634K	M84.641K	M84.642K	M84.650K	M84.651K	M84.652K	M84.659K
M84.661K	M84.662K	M84.663K	M84.664K	M84.671K	M84.672K	M84.674K
M84.675K	M84.68XK	M84.750G	M84.750K	M84.754G	M84.754K	M84.755G
M84.755K	M84.756G	M84.756K	M84.757G	M84.757K	M84.758G	M84.758K
M84.759G	M84.759K	N18.1	N18.2	N18.3	N18.4	N18.5
N18.6	N18.9	S22.20XK	S22.21XK	S22.22XK	S22.23XK	S22.24XK
S22.31XK	S22.32XK	S22.39XK	S22.41XK	S22.42XK	S22.43XK	S22.49XK
S22.5XXK	S22.9XXK	S32.301K	S32.302K	S32.311K	S32.312K	S32.314K
S32.315K	S32.391K	S32.392K	S32.401K	S32.402K	S32.411K	S32.412K
S32.414K	S32.415K	S32.421K	S32.422K	S32.424K	S32.425K	S32.431K
S32.432K	S32.434K	S32.435K	S32.441K	S32.442K	S32.444K	S32.445K
S32.451K	S32.452K	S32.454K	S32.455K	S32.461K	S32.462K	S32.464K
S32.465K	S32.471K	S32.472K	S32.474K	S32.475K	S32.481K	S32.482K
S32.484K	S32.485K	S32.491K	S32.492K	S32.501K	S32.502K	S32.511K
S32.512K	S32.591K	S32.592K	S32.601K	S32.602K	S32.611K	S32.612K
S32.614K	S32.615K	S32.691K	S32.692K	S32.810K	S32.811K	S42.001K
S42.002K	S42.011K	S42.012K	S42.014K	S42.015K	S42.017K	S42.018K
S42.021K	S42.022K	S42.024K	S42.025K	S42.031K	S42.032K	S42.034K
S42.035K	S42.101K	S42.102K	S42.111K	S42.112K	S42.114K	S42.115K
S42.121K	S42.122K	S42.124K	S42.125K	S42.131K	S42.132K	S42.134K
S42.135K	S42.141K	S42.142K	S42.144K	S42.145K	S42.151K	S42.152K
S42.154K	S42.155K	S42.191K	S42.192K	S42.201K	S42.202K	S42.211K
S42.212K	S42.214K	S42.215K	S42.221K	S42.222K	S42.224K	S42.225K
S42.231K	S42.232K	S42.241K	S42.242K	S42.251K	S42.252K	S42.254K
S42.255K	S42.261K	S42.262K	S42.264K	S42.265K	S42.271K	S42.272K
S42.291K	S42.292K	S42.294K	S42.295K	S42.301K	S42.302K	S42.311K
S42.312K	S42.321K	S42.322K	S42.324K	S42.325K	S42.331K	S42.332K
S42.334K	S42.335K	S42.341K	S42.342K	S42.344K	S42.345K	S42.351K
S42.352K	S42.354K	S42.355K	S42.361K	S42.362K	S42.364K	S42.365K
S42.391K	S42.392K	S42.401K	S42.402K	S42.411K	S42.412K	S42.414K
S42.415K	S42.421K	S42.422K	S42.424K	S42.425K	S42.431K	S42.432K
S42.434K	S42.435K	S42.441K	S42.442K	S42.444K	S42.445K	S42.447K
S42.448K	S42.451K	S42.452K	S42.454K	S42.455K	S42.461K	S42.462K
S42.464K	S42.465K	S42.471K	S42.472K	S42.474K	S42.475K	S42.481K
S42.482K	S42.491K	S42.492K	S42.494K	S42.495K	S42.91XK	S42.92XK
S49.001K	S49.002K	S49.011K	S49.012K	S49.021K	S49.022K	S49.031K
S49.032K	S49.041K	S49.042K	S49.091K	S49.092K	S49.101K	S49.102K
S49.111K	S49.112K	S49.121K	S49.122K	S49.131K	S49.132K	S49.141K
S49.142K	S49.191K	S49.192K	S52.001K	S52.001M	S52.001N	S52.002K
S52.002M	S52.002N	S52.011K	S52.012K	S52.021K	S52.021M	S52.021N
S52.022K	S52.022M	S52.022N	S52.024K	S52.024M	S52.024N	S52.025K
S52.025M	S52.025N	S52.031K	S52.031M	S52.031N	S52.032K	S52.032M
S52.032N	S52.034K	S52.034M	S52.034N	S52.035K	S52.035M	S52.035N
S52.041K	S52.041M	S52.041N	S52.042K	S52.042M	S52.042N	S52.044K
S52.044M	S52.044N	S52.045K	S52.045M	S52.045N	S52.091K	S52.091M
S52.091N	S52.092K	S52.092M	S52.092N	S52.101K	S52.101M	S52.101N
S52.102K	S52.102M	S52.102N	S52.111K	S52.112K	S52.121K	S52.121M
S52.121N	S52.122K	S52.122M	S52.122N	S52.124K	S52.124M	S52.124N
S52.125K	S52.125M	S52.125N	S52.131K	S52.131M	S52.131N	S52.132K
S52.132M	S52.132N	S52.134K	S52.134M	S52.134N	S52.135K	S52.135M
S52.135N	S52.181K	S52.181M	S52.181N	S52.182K	S52.182M	S52.182N
S52.201K	S52.201M	S52.201N	S52.202K	S52.202M	S52.202N	S52.211K
S52.212K	S52.221K	S52.221M	S52.221N	S52.222K	S52.222M	S52.222N
S52.224K	S52.224M	S52.224N	S52.225K	S52.225M	S52.225N	S52.231K
S52.231M	S52.231N	S52.232K	S52.232M	S52.232N	S52.234K	S52.234M
S52.234N	S52.235K	S52.235M	S52.235N	S52.241K	S52.241M	S52.241N
S52.242K	S52.242M	S52.242N	S52.244K	S52.244M	S52.244N	S52.245K
S52.245M	S52.245N	S52.251K	S52.251M	S52.251N	S52.252K	S52.252M
S52.252N	S52.254K	S52.254M	S52.254N	S52.255K	S52.255M	S52.255N
S52.261K	S52.261M	S52.261N	S52.262K	S52.262M	S52.262N	S52.264K
S52.264M	S52.264N	S52.265K	S52.265M	S52.265N	S52.271K	S52.271M
S52.271N	S52.272K	S52.272M	S52.272N	S52.281K	S52.281M	S52.281N
S52.282K	S52.282M	S52.282N	S52.291K	S52.291M	S52.291N	S52.292K
S52.292M	S52.292N	S52.301K	S52.301M	S52.301N	S52.302K	S52.302M
S52.302N	S52.311K	S52.312K	S52.321K	S52.321M	S52.321N	S52.322K
S52.322M	S52.322N	S52.324K	S52.324M	S52.324N	S52.325K	S52.325M
S52.325N	S52.331K	S52.331M	S52.331N	S52.332K	S52.332M	S52.332N
S52.334K	S52.334M	S52.334N	S52.335K	S52.335M	S52.335N	S52.341K
S52.341M	S52.341N	S52.342K	S52.342M	S52.342N	S52.344K	S52.344M
S52.344N	S52.345K	S52.345M	S52.345N	S52.351K	S52.351M	S52.351N
S52.352K	S52.352M	S52.352N	S52.354K	S52.354M	S52.354N	S52.355K
S52.355M	S52.355N	S52.361K	S52.361M	S52.361N	S52.362K	S52.362M
S52.362N	S52.364K	S52.364M	S52.364N	S52.365K	S52.365M	S52.365N
S52.371K	S52.371M	S52.371N	S52.372K	S52.372M	S52.372N	S52.381K
S52.381M	S52.381N	S52.382K	S52.382M	S52.382N	S52.391K	S52.391M
S52.391N	S52.392K	S52.392M	S52.392N	S52.501K	S52.501M	S52.501N
S52.502K	S52.502M	S52.502N	S52.511K	S52.511M	S52.511N	S52.512K
S52.512M	S52.512N	S52.514K	S52.514M	S52.514N	S52.515K	S52.515M
S52.515N	S52.521K	S52.522K	S52.531K	S52.531M	S52.531N	S52.532K
S52.532M	S52.532N	S52.541K	S52.541M	S52.541N	S52.542K	S52.542M
S52.542N	S52.551K	S52.551M	S52.551N	S52.552K	S52.552M	S52.552N
S52.561K	S52.561M	S52.561N	S52.562K	S52.562M	S52.562N	S52.571K
S52.571M	S52.571N	S52.572K	S52.572M	S52.572N	S52.591K	S52.591M
S52.591N	S52.592K	S52.592M	S52.592N	S52.601K	S52.601M	S52.601N
S52.602K	S52.602M	S52.602N	S52.611K	S52.611M	S52.611N	S52.612K
S52.612M	S52.612N	S52.614K	S52.614M	S52.614N	S52.615K	S52.615M
S52.615N	S52.621K	S52.622K	S52.691K	S52.691M	S52.691N	S52.692K
S52.692M	S52.692N	S52.90XK	S52.90XM	S52.90XN	S52.91XK	S52.91XM
S52.91XN	S52.92XK	S52.92XM	S52.92XN	S59.001K	S59.002K	S59.011K
S59.012K	S59.021K	S59.022K	S59.031K	S59.032K	S59.041K	S59.042K
S59.091K	S59.092K	S59.101K	S59.102K	S59.111K	S59.112K	S59.121K
S59.122K	S59.131K	S59.132K	S59.141K	S59.142K	S59.191K	S59.192K
S59.201K	S59.202K	S59.211K	S59.212K	S59.221K	S59.222K	S59.231K
S59.232K	S59.241K	S59.242K	S59.291K	S59.292K	S62.001A	S62.001K
S62.002A	S62.002K	S62.011A	S62.011K	S62.012A	S62.012K	S62.014A
S62.014K	S62.015A	S62.015K	S62.021A	S62.021K	S62.022A	S62.022K
S62.024A	S62.024K	S62.025A	S62.025K	S62.031A	S62.031K	S62.032A
S62.032K	S62.034A	S62.034K	S62.035A	S62.035K	S62.101K	S62.102K
S62.111K	S62.112K	S62.114K	S62.115K	S62.121K	S62.122K	S62.124K
S62.125K	S62.131K	S62.132K	S62.134K	S62.135K	S62.141K	S62.142K
S62.144K	S62.145K	S62.151K	S62.152K	S62.154K	S62.155K	S62.161K
S62.162K	S62.164K	S62.165K	S62.171K	S62.172K	S62.174K	S62.175K
S62.181K	S62.182K	S62.184K	S62.185K	S62.201K	S62.202K	S62.211K
S62.212K	S62.221K	S62.222K	S62.224K	S62.225K	S62.231K	S62.232K
S62.234K	S62.235K	S62.241K	S62.242K	S62.244K	S62.245K	S62.251K
S62.252K	S62.254K	S62.255K	S62.291K	S62.292K	S62.300K	S62.301K
S62.302K	S62.303K	S62.304K	S62.305K	S62.306K	S62.307K	S62.310K
S62.311K	S62.312K	S62.313K	S62.314K	S62.315K	S62.316K	S62.317K
S62.320K	S62.321K	S62.322K	S62.323K	S62.324K	S62.325K	S62.326K
S62.327K	S62.330K	S62.331K	S62.332K	S62.333K	S62.334K	S62.335K
S62.336K	S62.337K	S62.340K	S62.341K	S62.342K	S62.343K	S62.344K
S62.345K	S62.346K	S62.347K	S62.348K	S62.349K	S62.350K	S62.351K
S62.352K	S62.353K	S62.354K	S62.355K	S62.356K	S62.357K	S62.360K
S62.361K	S62.362K	S62.363K	S62.364K	S62.365K	S62.366K	S62.367K
S62.390K	S62.391K	S62.392K	S62.393K	S62.394K	S62.395K	S62.396K
S62.397K	S62.501K	S62.502K	S62.511K	S62.512K	S62.514K	S62.515K
S62.521K	S62.522K	S62.524K	S62.525K	S62.600K	S62.601K	S62.602K
S62.603K	S62.604K	S62.605K	S62.606K	S62.607K	S62.610K	S62.611K
S62.612K	S62.613K	S62.614K	S62.615K	S62.616K	S62.617K	S62.620K
S62.621K	S62.622K	S62.623K	S62.624K	S62.625K	S62.626K	S62.627K
S62.630K	S62.631K	S62.632K	S62.633K	S62.634K	S62.635K	S62.636K
S62.637K	S62.640K	S62.641K	S62.642K	S62.643K	S62.644K	S62.645K
S62.646K	S62.647K	S62.650K	S62.651K	S62.652K	S62.653K	S62.654K
S62.655K	S62.656K	S62.657K	S62.660K	S62.661K	S62.662K	S62.663K
S62.664K	S62.665K	S62.666K	S62.667K	S62.91XK	S62.92XK	S72.001K
S72.001M	S72.001N	S72.002K	S72.002M	S72.002N	S72.011K	S72.011M
S72.011N	S72.012K	S72.012M	S72.012N	S72.021K	S72.021M	S72.021N
S72.022K	S72.022M	S72.022N	S72.024K	S72.024M	S72.024N	S72.025K
S72.025M	S72.025N	S72.031K	S72.031M	S72.031N	S72.032K	S72.032M
S72.032N	S72.034K	S72.034M	S72.034N	S72.035K	S72.035M	S72.035N
S72.041K	S72.041M	S72.041N	S72.042K	S72.042M	S72.042N	S72.044K
S72.044M	S72.044N	S72.045K	S72.045M	S72.045N	S72.051K	S72.051M
S72.051N	S72.052K	S72.052M	S72.052N	S72.061K	S72.061M	S72.061N
S72.062K	S72.062M	S72.062N	S72.064K	S72.064M	S72.064N	S72.065K
S72.065M	S72.065N	S72.091K	S72.091M	S72.091N	S72.092K	S72.092M
S72.092N	S72.101K	S72.101M	S72.101N	S72.102K	S72.102M	S72.102N
S72.111K	S72.111M	S72.111N	S72.112K	S72.112M	S72.112N	S72.114K
S72.114M	S72.114N	S72.115K	S72.115M	S72.115N	S72.121K	S72.121M
S72.121N	S72.122K	S72.122M	S72.122N	S72.124K	S72.124M	S72.124N
S72.125K	S72.125M	S72.125N	S72.131K	S72.131M	S72.131N	S72.132K
S72.132M	S72.132N	S72.134K	S72.134M	S72.134N	S72.135K	S72.135M
S72.135N	S72.141K	S72.141M	S72.141N	S72.142K	S72.142M	S72.142N
S72.144K	S72.144M	S72.144N	S72.145K	S72.145M	S72.145N	S72.21XK
S72.21XM	S72.21XN	S72.22XK	S72.22XM	S72.22XN	S72.24XK	S72.24XM
S72.24XN	S72.25XK	S72.25XM	S72.25XN	S72.301K	S72.301M	S72.301N
S72.302K	S72.302M	S72.302N	S72.321K	S72.321M	S72.321N	S72.322K
S72.322M	S72.322N	S72.324K	S72.324M	S72.324N	S72.325K	S72.325M
S72.325N	S72.331K	S72.331M	S72.331N	S72.332K	S72.332M	S72.332N
S72.334K	S72.334M	S72.334N	S72.335K	S72.335M	S72.335N	S72.341K
S72.341M	S72.341N	S72.342K	S72.342M	S72.342N	S72.344K	S72.344M
S72.344N	S72.345K	S72.345M	S72.345N	S72.351K	S72.351M	S72.351N
S72.352K	S72.352M	S72.352N	S72.354K	S72.354M	S72.354N	S72.355K
S72.355M	S72.355N	S72.361K	S72.361M	S72.361N	S72.362K	S72.362M
S72.362N	S72.364K	S72.364M	S72.364N	S72.365K	S72.365M	S72.365N
S72.391K	S72.391M	S72.391N	S72.392K	S72.392M	S72.392N	S72.401K
S72.401M	S72.401N	S72.402K	S72.402M	S72.402N	S72.411K	S72.411M
S72.411N	S72.412K	S72.412M	S72.412N	S72.414K	S72.414M	S72.414N
S72.415K	S72.415M	S72.415N	S72.421K	S72.421M	S72.421N	S72.422K
S72.422M	S72.422N	S72.424K	S72.424M	S72.424N	S72.425K	S72.425M
S72.425N	S72.431K	S72.431M	S72.431N	S72.432K	S72.432M	S72.432N
S72.434K	S72.434M	S72.434N	S72.435K	S72.435M	S72.435N	S72.441K
S72.441M	S72.441N	S72.442K	S72.442M	S72.442N	S72.444K	S72.444M
S72.444N	S72.445K	S72.445M	S72.445N	S72.451K	S72.451M	S72.451N
S72.452K	S72.452M	S72.452N	S72.454K	S72.454M	S72.454N	S72.455K
S72.455M	S72.455N	S72.461K	S72.461M	S72.461N	S72.462K	S72.462M
S72.462N	S72.464K	S72.464M	S72.464N	S72.465K	S72.465M	S72.465N
S72.471K	S72.472K	S72.491K	S72.491M	S72.491N	S72.492K	S72.492M
S72.492N	S72.8X1K	S72.8X1M	S72.8X1N	S72.8X2K	S72.8X2M	S72.8X2N
S72.8X9K	S72.8X9M	S72.8X9N	S72.91XK	S72.91XM	S72.91XN	S72.92XK
S72.92XM	S72.92XN	S79.001K	S79.002K	S79.011K	S79.012K	S79.091K
S79.092K	S79.101K	S79.102K	S79.111K	S79.112K	S79.121K	S79.122K
S79.131K	S79.132K	S79.141K	S79.142K	S79.191K	S79.192K	S82.001K
S82.001M	S82.001N	S82.002K	S82.002M	S82.002N	S82.011K	S82.011M
S82.011N	S82.012K	S82.012M	S82.012N	S82.014K	S82.014M	S82.014N
S82.015K	S82.015M	S82.015N	S82.021K	S82.021M	S82.021N	S82.022K
S82.022M	S82.022N	S82.024K	S82.024M	S82.024N	S82.025K	S82.025M
S82.025N	S82.031K	S82.031M	S82.031N	S82.032K	S82.032M	S82.032N
S82.034K	S82.034M	S82.034N	S82.035K	S82.035M	S82.035N	S82.041K
S82.041M	S82.041N	S82.042K	S82.042M	S82.042N	S82.044K	S82.044M
S82.044N	S82.045K	S82.045M	S82.045N	S82.091K	S82.091M	S82.091N
S82.092K	S82.092M	S82.092N	S82.101K	S82.101M	S82.101N	S82.102K
S82.102M	S82.102N	S82.111K	S82.111M	S82.111N	S82.112K	S82.112M
S82.112N	S82.114K	S82.114M	S82.114N	S82.115K	S82.115M	S82.115N
S82.121K	S82.121M	S82.121N	S82.122K	S82.122M	S82.122N	S82.124K
S82.124M	S82.124N	S82.125K	S82.125M	S82.125N	S82.131K	S82.131M
S82.131N	S82.132K	S82.132M	S82.132N	S82.134K	S82.134M	S82.134N
S82.135K	S82.135M	S82.135N	S82.141K	S82.141M	S82.141N	S82.142K
S82.142M	S82.142N	S82.144K	S82.144M	S82.144N	S82.145K	S82.145M
S82.145N	S82.151K	S82.151M	S82.151N	S82.152K	S82.152M	S82.152N
S82.154K	S82.154M	S82.154N	S82.155K	S82.155M	S82.155N	S82.161K
S82.162K	S82.191K	S82.191M	S82.191N	S82.192K	S82.192M	S82.192N
S82.201K	S82.201M	S82.201N	S82.202K	S82.202M	S82.202N	S82.221K
S82.221M	S82.221N	S82.222K	S82.222M	S82.222N	S82.224K	S82.224M
S82.224N	S82.225K	S82.225M	S82.225N	S82.231K	S82.231M	S82.231N
S82.232K	S82.232M	S82.232N	S82.234K	S82.234M	S82.234N	S82.235K
S82.235M	S82.235N	S82.241K	S82.241M	S82.241N	S82.242K	S82.242M
S82.242N	S82.244K	S82.244M	S82.244N	S82.245K	S82.245M	S82.245N
S82.251K	S82.251M	S82.251N	S82.252K	S82.252M	S82.252N	S82.254K
S82.254M	S82.254N	S82.255K	S82.255M	S82.255N	S82.261K	S82.261M
S82.261N	S82.262K	S82.262M	S82.262N	S82.264K	S82.264M	S82.264N
S82.265K	S82.265M	S82.265N	S82.291K	S82.291M	S82.291N	S82.292K
S82.292M	S82.292N	S82.301K	S82.301M	S82.301N	S82.302K	S82.302M
S82.302N	S82.311K	S82.312K	S82.391K	S82.391M	S82.391N	S82.392K
S82.392M	S82.392N	S82.401K	S82.401M	S82.401N	S82.402K	S82.402M
S82.402N	S82.421K	S82.421M	S82.421N	S82.422K	S82.422M	S82.422N
S82.424K	S82.424M	S82.424N	S82.425K	S82.425M	S82.425N	S82.431K
S82.431M	S82.431N	S82.432K	S82.432M	S82.432N	S82.434K	S82.434M
S82.434N	S82.435K	S82.435M	S82.435N	S82.441K	S82.441M	S82.441N
S82.442K	S82.442M	S82.442N	S82.444K	S82.444M	S82.444N	S82.445K
S82.445M	S82.445N	S82.451K	S82.451M	S82.451N	S82.452K	S82.452M
S82.452N	S82.454K	S82.454M	S82.454N	S82.455K	S82.455M	S82.455N
S82.461K	S82.461M	S82.461N	S82.462K	S82.462M	S82.462N	S82.464K
S82.464M	S82.464N	S82.465K	S82.465M	S82.465N	S82.491K	S82.491M
S82.491N	S82.492K	S82.492M	S82.492N	S82.51XK	S82.51XM	S82.51XN
S82.52XK	S82.52XM	S82.52XN	S82.54XK	S82.54XM	S82.54XN	S82.55XK
S82.55XM	S82.55XN	S82.61XK	S82.61XM	S82.61XN	S82.62XK	S82.62XM
S82.62XN	S82.64XK	S82.64XM	S82.64XN	S82.65XK	S82.65XM	S82.65XN
S82.811K	S82.812K	S82.821K	S82.822K	S82.831K	S82.831M	S82.831N
S82.832K	S82.832M	S82.832N	S82.841K	S82.841M	S82.841N	S82.842K
S82.842M	S82.842N	S82.844K	S82.844M	S82.844N	S82.845K	S82.845M
S82.845N	S82.851K	S82.851M	S82.851N	S82.852K	S82.852M	S82.852N
S82.854K	S82.854M	S82.854N	S82.855K	S82.855M	S82.855N	S82.861K
S82.861M	S82.861N	S82.862K	S82.862M	S82.862N	S82.864K	S82.864M
S82.864N	S82.865K	S82.865M	S82.865N	S82.871K	S82.871M	S82.871N
S82.872K	S82.872M	S82.872N	S82.874K	S82.874M	S82.874N	S82.875K
S82.875M	S82.875N	S82.891K	S82.891M	S82.891N	S82.892K	S82.892M
S82.892N	S82.91XK	S82.91XM	S82.91XN	S82.92XK	S82.92XM	S82.92XN
S89.001K	S89.002K	S89.011K	S89.012K	S89.021K	S89.022K	S89.031K
S89.032K	S89.041K	S89.042K	S89.091K	S89.092K	S89.101K	S89.102K
S89.111K	S89.112K	S89.121K	S89.122K	S89.131K	S89.132K	S89.141K
S89.142K	S89.191K	S89.192K	S89.201K	S89.202K	S89.211K	S89.212K
S89.221K	S89.222K	S89.291K	S89.292K	S89.301K	S89.302K	S89.311K
S89.312K	S89.321K	S89.322K	S89.391K	S89.392K	S92.001K	S92.002K
S92.011K	S92.012K	S92.014K	S92.015K	S92.021K	S92.022K	S92.024K
S92.025K	S92.031K	S92.032K	S92.034K	S92.035K	S92.041K	S92.042K
S92.044K	S92.045K	S92.051K	S92.052K	S92.054K	S92.055K	S92.061K
S92.062K	S92.064K	S92.065K	S92.101K	S92.102K	S92.111K	S92.112K
S92.114K	S92.115K	S92.121K	S92.122K	S92.124K	S92.125K	S92.131K
S92.132K	S92.134K	S92.135K	S92.141K	S92.142K	S92.144K	S92.145K
S92.151K	S92.152K	S92.154K	S92.155K	S92.191K	S92.192K	S92.201K
S92.202K	S92.211K	S92.212K	S92.214K	S92.215K	S92.221K	S92.222K
S92.224K	S92.225K	S92.231K	S92.232K	S92.234K	S92.235K	S92.241K
S92.242K	S92.244K	S92.245K	S92.251K	S92.252K	S92.254K	S92.255K
S92.301A	S92.301K	S92.302A	S92.302K	S92.311K	S92.312K	S92.313A
S92.313K	S92.314A	S92.314K	S92.315A	S92.315K	S92.321A	S92.321K
S92.322A	S92.322K	S92.324A	S92.324K	S92.325A	S92.325K	S92.331A
S92.331K	S92.332A	S92.332K	S92.334A	S92.334K	S92.335A	S92.335K
S92.341A	S92.341K	S92.342A	S92.342K	S92.344A	S92.344K	S92.345A
S92.345K	S92.351A	S92.351K	S92.352A	S92.352K	S92.354A	S92.354K
S92.355A	S92.355K	S92.401K	S92.402K	S92.404K	S92.405K	S92.411K
S92.412K	S92.414K	S92.415K	S92.421K	S92.422K	S92.424K	S92.425K
S92.491K	S92.492K	S92.501K	S92.502K	S92.504K	S92.505K	S92.511K
S92.512K	S92.514K	S92.515K	S92.521K	S92.522K	S92.524K	S92.525K
S92.531K	S92.532K	S92.534K	S92.535K	S92.591K	S92.592K	S92.901K
S92.902K	S92.911K	S92.912K	S92.919K	Z92.240	Z92.241

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