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Ultrasound Osteogenesis Stimulator

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

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 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
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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
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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
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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
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S62.637K S62.640K S62.641K S62.642K S62.643K S62.644K S62.645K
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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
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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
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S72.114M S72.114N S72.115K S72.115M S72.115N S72.121K S72.121M
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S72.135N S72.141K S72.141M S72.141N S72.142K S72.142M S72.142N
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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
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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
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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
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