Electrical and Ultrasound Bone Growth Stimulators - Oxford Health ...

ELECTRICAL AND ULTRASOUNDBONE GROWTH STIMULATORSCLINICAL POLICYPolicy Number: DME 006.14 T2Effective Date: January 1, 2014Table of ContentsCONDITIONS OF COVERAGE...................................COVERAGE RATIONALE...........................................U.S. FOOD AND DRUG ADMINISTRATION...............APPLICABLE CODES.................................................REFERENCES............................................................POLICY HISTORY/REVISION INFORMATION...........Page112222Related Policies:NoneThe services described in Oxford policies are subject to the terms, conditions and limitations of the Member'scontract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantageenrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior writtennotice unless otherwise required by Oxford's administrative procedures or applicable state law. The termOxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to theMember's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there areany exclusions or benefit limitations applicable to any of these policies. If there is a difference between anypolicy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate ofCoverage will govern.CONDITIONS OF COVERAGEApplicable Lines of Business/Products This policy applies to Oxford Commercial planmembership.Benefit Type General benefits package 1Referral Required(Does not apply to non-gatekeeper products)Authorization Required(Precertification always required for inpatient admission)Precertification with Medical DirectorReview RequiredApplicable Site(s) of Service(If site of service is not listed, Medical Director review isrequired)Special ConsiderationsCOVERAGE RATIONALEDurable Medical Equipment (DME) 2NoYesNoInpatient, Outpatient, Home1 CPT codes 20974, 20975 and 20979.2 HCPCS codes E0747, E0748, E0749 andE0760.Two MCG Care Guidelines are identified, one for electrical and electromagnetic bone growthstimulators, and one for Ultrasonic Bone Growth Stimulators.Electrical and Ultrasound Bone Growth Stimulators: Clinical Policy (Effective 01/01/2014)©1996-2014, Oxford Health Plans, LLC1

For information regarding medical necessity review of electrical and electromagnetic bone growthstimulators, see MCG Care Guidelines, 17th Edition, 2013, Bone Growth Stimulators, Electricaland Electromagnetic ACG: A-0565 (AC).For information regarding medical necessity review of ultrasonic bone growth stimulators, seeMCG Care Guidelines, 17th Edition, 2013, Bone Growth Stimulators, Ultrasonic ACG: A-0414(AC).U.S. FOOD AND DRUG ADMINISTRATION (FDA)The FDA regards bone growth stimulators as significant-risk (Class III) devices. The FDA hasapproved numerous bone growth stimulation devices. Search the following Web site for furtherinformation (use product code LOF for noninvasive devices, LOE for invasive devices and LPQfor ultrasonic devices). Available at:http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm. Accessed October 2013.APPLICABLE CODESThe codes listed in this policy are for reference purposes only. Listing of a service or device codein this policy does not imply that the service described by this code is a covered or non-coveredhealth service. Coverage is determined by the Member’s plan of benefits or Certificate ofCoverage. This list of codes may not be all inclusive.CPT ® CodeDescription20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative)20975 Electrical stimulation to aid bone healing; invasive (operative)20979Low intensity ultrasound stimulation to aid bone healing, noninvasive(nonoperative)CPT ® is a registered trademark of the American Medical Association.HCPCS CodeE0747E0748E0749E0760DescriptionOsteogenesis stimulator, electrical, noninvasive, other than spinalapplicationsOsteogenesis stimulator, electrical, noninvasive, spinal applicationsOsteogenesis stimulator, electrical, surgically implantedOsteogenesis stimulator, low intensity ultrasound, non-invasiveREFERENCESThe foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policythat was researched, developed and approved by UnitedHealthcare Medical TechnologyAssessment Committee. [2014T0561B]POLICY HISTORY/REVISION INFORMATIONDate01/01/2014Action/Description• Updated description of services to reflect most current FDAinformation; no change to coverage rationale or lists of applicablecodes• Archived previous policy version DME 006.13 T2Electrical and Ultrasound Bone Growth Stimulators: Clinical Policy (Effective 01/01/2014)©1996-2014, Oxford Health Plans, LLC2