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| Medical Policy: | S-89-021 |
| Topic: | Bone Growth Stimulation |
| Section: | Surgery |
| Effective Date: | October 1, 2017 |
| Issue Date: | October 2, 2017 |
| Last Reviewed: | January 2017 |
Bone growth stimulation is also known as osteogenesis stimulation and is used when the body's healing process fails to heal bone injuries. The bone growth stimulation device stimulates the natural healing process of the bone by sending low-level pulses of electromagnetic energy to the injury site. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Both invasive and noninvasive non-spinal electrical bone growth stimulation are eligible for payment in the treatment of a non-united fracture. A non-united fracture is defined as a fracture that has not healed within a minimum of three (3) months of the original fracture.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of fracture nonunion or congenital pseudoarthrosis in the appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper extremities, pelvis and lower extremities).
The diagnosis of non-spinal fracture nonunion or congenital pseudoarthrosis must meet ALL of the following criteria:
ANY ONE of the following:
- At least three (3) months have passed since the date of the fracture; or
- At least three (3) months since the date of the surgical treatment of the fracture
AND
ALL of the following:
- Serial radiographs have confirmed that no progressive signs of healing have occurred; and
- The fracture gap is one (1) centimeter or less; and
- The patient can be adequately immobilized and is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities.
Non-spinal Electrical Bone Growth Stimulation (EBGS) will be denied as not medically necessary if the preceding criteria are not met.
When the doctor reports electrical stimulation, the claim should be processed under the appropriate code for electrical stimulation. Use of the device is included in the doctor's global allowance for the electrical stimulation (i.e., no separate payment can be made for the device).
However, if the patient employs the stimulator at home, rental or purchase of the device may be eligible for payment. In this instance, any charges reported by the doctor for electrical stimulation should be denied as not medically necessary.
Re-casting is considered part of the global surgical allowance for the stimulation. Therefore, re-casting is not eligible for separate payment.
EBGS and Spinal Fusion
Electrical bone growth stimulation (EBGS) (invasive or non-invasive methods) of the spine may be considered medically necessary as an adjunct to lumbar spinal fusion surgery for members who are considered high-risk for spinal fusion failure when ANY of the following criteria is met:
- A multiple-level fusion entailing 3 or more vertebrae (e.g., L3 to L5, L4 to S1, etc.); or
- Grade II or worse spondylolisthesis; or
- One or more failed fusions; or
- ONE OR MORE of the following risk factors for fusion failure are present:
- Gross obesity (BMI greater than 40); or
- Current smoking; or
- Diabetes; or
- Renal disease; or
- Active alcoholism; or
- Chronic long-term steroid use.
EBGS (invasive or non-invasive methods) of the spine will be denied as not medically necessary if the preceding criteria are not met.
Noninvasive EBGS may be considered medically necessary as a treatment of patients with failed lumbar spinal fusion. Failed spinal fusion is defined as a spinal fusion that has not healed at a minimum of 6 months after the original surgery, as evidenced by serial radiographs over a course of 3 months.
If the patient employs the noninvasive EBGS stimulator at home, coverage for the rental or purchase of the device is determined according to individual or group customer benefits. In this instance, any charges reported by the doctor for noninvasive EBGS of the spine should be denied as not medically necessary.
Semi-invasive EBGS is considered not medically necessary as an adjunct to lumbar fusion surgery and for failed lumbar fusion.
Invasive, semi-invasive, and noninvasive EBGS is considered not medically necessary as an adjunct to cervical fusion surgery and/or for failed cervical spine fusion.
Invasive EBGS of the spine should be reported in accordance with multiple surgery payment guidelines.
Refer to medical policy E-35 Ultrasound Osteogenesis Stimulator for additional information. |
| Place of Service: Outpatient |
Bone Growth Stimulation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
02/2017, Criteria Revised for Electrical Bone Growth Stimulation of the Spine
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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