Ultrasound Osteogenesis Stimulator

Policy ID: E-35-025

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: September 25, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

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 to stimulate fracture healing.

Criteria

An ultrasonic osteogenesis stimulator may be considered medically necessary when 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

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 newly diagnosed or recent fractures (up to fourteen (14) days after the fracture occurs), or closed fractures of a skeletally mature individual.

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:
- 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.

Procedure Codes

20979

E0760

Osteogenesis stimulators not meeting the criteria as indicated in this policy are considered 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 noninvasive osteogenesis stimulators.

Procedure Codes

20979

E0760

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

Procedure Codes

E0747

Diagnosis Codes

Covered diagnosis codes for procedure codes 20979, 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

M80.011K

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

M80.0AXG

M80.0AXK

M80.0B1A

M80.0B1D

M80.0B1G

M80.0B1K

M80.0B1P

M80.0B1S

M80.0B2A

M80.0B2D

M80.0B2G

M80.0B2K

M80.0B2P

M80.0B2S

M80.0B9A

M80.0B9D

M80.0B9G

M80.0B9K

M80.0B9P

M80.0B9S

M80.8B1A

M80.8B1D

M80.8B1G

M80.8B1K

M80.8B1P

M80.8B1S

M80.8B2A

M80.8B2D

M80.8B2G

M80.8B2K

M80.8B2P

M80.8B2S

M80.8B9A

M80.8B9D

M80.8B9G

M80.8B9K

M80.8B9P

M80.8B9S

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

M80.8AXG

M80.8AXK

M81.6

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

M84.461K

M84.462K

M84.463K

M84.464K

M84.471K

M84.472K

M84.474K

M84.475K

M84.477K

M84.478K

M84.48XK

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

M84.661K

M84.662K

M84.663K

M84.664K

M84.671K

M84.672K

M84.674K

M84.675K

M84.754G

M84.754K

M84.755G

M84.755K

M84.756G

M84.757G

M84.757K

M84.758G

M84.758K

N18.1

N18.2

N18.3

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

S22.41XK

S22.42XK

S22.43XK

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

S52.91XK

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

S72.91XK

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

S92.314A

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

Z79.01

Z79.51

Z79.52

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, and
some diagnosis updates; and
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

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 7-21-2022 Coding update - Effective September 05, 2022

Removed Procedure code: A4559; and
Removed Diagnosis codes: S22.32XK; S2.39XK; 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; S32.411K; S32.412K; S32.414K; S32.415K; S32.421K; S32.422K; S32.424K; S32.425K; S32.431K; S32.432K

Internal Medical Policy Committee 3-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 5-23-2023 Coding update - Effective July 03, 2023

Removed Diagnosis Codes M80.00XK, M80.80XK, M84.40XK, M84.459K, M84.60XK, M84.659K, M84.750G, M84.750K, M84.756K, M84.759G, M84.759K, S22.39XK, S22.49XK, S52.90XK, S52.90XM, S52.90XN, S72.8X9K, S72.8X9M, S72.8X9N, S92.313A, S92.313K, S92.919K; and
Added Diagnosis Codes: N18.3, Z79.01, Z79.51, Z79.52

Internal Medical Policy Committee11-15-2023 Coding update - Effective October 1, 2023

Added diagnosis codes M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80,0B2D, M80.0B2G, M80.0B2K, M80.0B2P, M80.0B2S, M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B1A, M80.8B1D, M80.8B1G, M80.8B1K, M80.8B1P, M80.8B1S, M80.8B2A, M80.8B2D, M80.8B2G, M80.8B2K, M80.8B2P, M80.8B2S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, M80.8B9S to procedure codes 20979 & E0760

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.

Policy ID: E-35-024

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: May 22, 2023

Revision Effective Date: July 03, 2023

Last Reviewed: May 23, 2023

Archived Date: September 24, 2023

Applies To: Commercial and Medicaid Expansion

Description

Criteria

An ultrasonic osteogenesis stimulator may be considered medically necessary when 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:
- 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.

Procedure Codes

20979

E0760

Osteogenesis stimulators not meeting the criteria as indicated in this policy are considered 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 noninvasive osteogenesis stimulators.

Procedure Codes

20979

E0760

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

Procedure Codes

E0747

Diagnosis Codes

Covered diagnosis codes for procedure codes 20979, 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

M80.011K

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

M80.0AXG

M80.0AXK

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

M80.8AXG

M80.8AXK

M81.6

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

M84.461K

M84.462K

M84.463K

M84.464K

M84.471K

M84.472K

M84.474K

M84.475K

M84.477K

M84.478K

M84.48XK

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

M84.661K

M84.662K

M84.663K

M84.664K

M84.671K

M84.672K

M84.674K

M84.675K

M84.754G

M84.754K

M84.755G

M84.755K

M84.756G

M84.757G

M84.757K

M84.758G

M84.758K

N18.1

N18.2

N18.3

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

S22.41XK

S22.42XK

S22.43XK

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

S52.91XK

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

S72.91XK

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

S92.314A

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

Z79.01

Z79.51

Z79.52

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, and
some diagnosis updates; and
updated to v. 19 .

Internal Medical Policy Committee 11-19-2020

Removed the following diagnosis codes:

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 7-21-2022 Coding update - Effective September 05, 2022

Removed Procedure code: A4559; and
RemovedDiagnosis codes: S22.32XK; S2.39XK; 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; S32.411K; S32.412K; S32.414K; S32.415K; S32.421K; S32.422K; S32.424K; S32.425K; S32.431K; S32.432K

Internal Medical Policy Committee 3-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 5-23-2023 Coding update - Effective July 03, 2023

Removed Diagnosis Codes M80.00XK, M80.80XK, M84.40XK, M84.459K, M84.60XK, M84.659K, M84.750G, M84.750K, M84.756K, M84.759G, M84.759K, S22.39XK, S22.49XK, S52.90XK, S52.90XM, S52.90XN, S72.8X9K, S72.8X9M, S72.8X9N, S92.313A, S92.313K, S92.919K; and
Added Diagnosis Codes: N18.3, Z79.01, Z79.51, Z79.52

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