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

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