CurrentArizona Complete HealthPolicy CP.MP.194

Osteogenic Stimulation

Defines medical necessity criteria, coding, and clinical background for noninvasive and invasive electrical osteogenic stimulators and low-intensity pulsed ultrasound devices used to enhance bone healing for members covered by the payer.

Policy Summary

PayerArizona Complete Health

PolicyOsteogenic Stimulation

Policy CodePolicy CP.MP.194

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document serial imaging and clinical criteria (e.g., infection status, gap <1 cm, stability) before initiating osteogenic stimulator therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8codes referenced

3types covered

>=90dnonunion timing (noninvasive)

6mfailed fusion timing (non-spine)

9mfailed fusion timing (spine)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Noninvasive electrical osteogenesis stimulators — Covered when ANY of the following apply

Noninvasive electrical osteogenesis stimulators are medically necessary when any of the following apply:

I.A: Nonunion of long bone fracture and at least 90 days have passed since the date of fracture or the date of surgical treatment of the fracture>=90 days

AND all of: bone not infected; gap between bone fragments < 1 cm; bone stable at both ends with appropriate fracture care and immobilization; serial imaging confirmed healing ceased for >=3 months prior to treatment with the noninvasive electrical bone growth stimulator. Serial imaging must include a minimum of two sets of images, each including multiple views of the fracture site, separated by a minimum of 90 days.

I.B: Failed fusion of a joint, other than the spine, in which a minimum of six months has elapsed since the last surgery>=6 months

I.C: Congenital pseudoarthrosis

I.D: As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion surgery or for those undergoing a multilevel spinal fusion (involving three or more vertebrae)multilevel = >=3 vertebrae

I.E: Risk of delayed or non-union of fractures due to certain conditions (including but not limited to alcoholism, chemotherapy, diabetes, obesity, osteoporosis, renal disease, tobacco or steroid use)

Invasive electrical osteogenesis stimulators — Covered when ANY of the following apply

Invasive electrical osteogenesis stimulators are medically necessary when any of the following apply:

II.A: Nonunion of long bone fracture and all of the following: the bone is not infected; the two portions of the bone involved in the nonunion are separated by less than one centimeter; the bone is stable at both ends by means of appropriate fracture care and immobilization; serial imaging has confirmed that fracture healing has ceased for three or more months prior to starting treatment with the invasive bone growth stimulator. Serial imaging must include a minimum of two sets of images, each including multiple views of the fracture site, separated by a minimum of 90 days.

II.B: Failed spinal fusion in which a minimum of nine months has elapsed since the last surgery and/or as an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis>=9 months

II.C: Following a multilevel spinal fusion (involving three or more vertebrae)multilevel = >=3 vertebrae

Ultrasonic osteogenesis stimulators — Covered when ANY of the following apply

Ultrasonic osteogenesis stimulators (LIPUS) are medically necessary when any of the following apply:

III.A: Used as an adjunct to conventional management (i.e., closed reduction and cast immobilization) for the treatment of fresh, closed fractures when there is high risk for delayed fracture healing or nonunion and the fracture is seven days old or less, and at least one listed risk factor is present (examples include fractures associated with extensive soft tissue or vascular damage; fresh, closed or grade I open short oblique or short spiral tibial diaphyseal fractures treated with closed reduction and cast immobilization in skeletally mature patients; fresh, closed distal radius (Colles') fractures; fresh Jones fracture (5th metatarsal); fresh scaphoid fractures)<=7 days

Intended as adjunctive therapy to standard fracture stabilization rather than first-line standalone therapy.

III.B: Nonunion of bones other than the skull or vertebrae in skeletally mature patients (excluding malignancy-related nonunions) when documented by a minimum of two sets of imaging obtained prior to starting treatment separated by at least 90 days, and the two portions of bone involved in the nonunion are separated by less than one centimeter>=90 days imaging separation; gap <1 cm

Ultrasonic (LIPUS) osteogenesis stimulators have explicit device- and indication-level exclusions. They are not medically necessary when used concurrently with other noninvasive osteogenic stimulators, for avascular necrosis of the femoral head, for stress fractures, for fractures with a gap that exceeds 1 cm, for fresh fractures located outside the specified anatomic sites (distal radius, tibial diaphysis, scaphoid, or Jones fracture of the 5th metatarsal), for fresh tibial diaphyseal or tibial/fibular fractures treated with closed reduction and intramedullary nailing when no risk factors for poor healing are present, for preoperative use when surgical fixation is required, and for tibial stress fractures. Additionally, osteogenic devices (including ultrasonic stimulators) are not medically necessary for nonunion fractures of the skull, vertebrae, or those related to tumor/malignancy.

Coverage determinations for osteogenic stimulation are governed by the member's coverage documents and applicable legal requirements. This policy is a guide to medical necessity and does not constitute a guarantee of payment. Coverage and administration of benefits remain subject to the member's evidence of coverage, certificate of coverage, contract terms, and any relevant state Medicaid or federal Medicare requirements; where discrepancies exist, state or federal mandates take precedence.

The scope of covered ultrasonic osteogenesis stimulators (LIPUS) is limited to specific clinical scenarios: adjunctive use for fresh, closed fractures at high risk of delayed healing or nonunion when the fracture is ≤7 days old and meets the listed risk/location criteria (for example, distal radius, scaphoid, Jones fracture, or selected tibial diaphyseal fractures treated nonoperatively), and for nonunion of bones other than the skull or vertebrae when imaging and clinical criteria are met (minimum two sets of images separated by ≥90 days and fracture gap <1 cm). Device-level limits align with the exclusions above — LIPUS is not indicated for use outside the specified anatomic sites, for fractures with gap >1 cm, preoperative use when surgery is required, tibial stress fractures, or concurrent use with other noninvasive osteogenic stimulators.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed procedure and device codes before initiation of osteogenic stimulation therapy. Providers must obtain authorization through the Health Plan's standard prior authorization process; authorization does not guarantee payment and is subject to member benefits, exclusions, and limitations.

Affected codes include (but are not limited to): CPT 20974, 20975, 20979; HCPCS E0747, E0748, E0749, E0760; A4559.
Ensure PA is obtained prior to service or device delivery to avoid claim denials.

Note

Health Plan May Require Adherence to Policy

The Health Plan may require adherence to this clinical policy when reviewing requests for osteogenic stimulation. Providers should submit complete clinical documentation to support medical necessity as outlined in the policy.

Documentation Required

Use Sequence for LIPUS

Low Intensity Pulsed Ultrasound (LIPUS) devices are prescribed for at-home daily use for approximately 20 minutes once daily as an adjunct to standard fracture stabilization (e.g., closed reduction and cast immobilization). Ensure the prescription and treatment plan document device type, daily duration, and intended treatment course.

Typical prescription: 20 minutes once daily until radiographic and clinical healing.
Document that LIPUS is being used in conjunction with appropriate fracture stabilization.

Documentation Required

Imaging Documentation for Nonunion

Providers must supply serial imaging to document nonunion prior to initiation of osteogenic stimulation. Serial imaging requires at least two sets of images, each including multiple views of the fracture site, separated by a minimum of 90 days, demonstrating that fracture healing has ceased for three or more months (for noninvasive electrical stimulators) or appropriate intervals per device-specific criteria.

Minimum: two imaging sets with multiple views, separated by >= 90 days.
Imaging should demonstrate lack of progression of healing for the required timeframe (e.g., ≥3 months for noninvasive electrical stimulators).

Documentation Required

Clinical Documentation Requirements for Nonunion

Clinical documentation must confirm key nonunion and patient-status criteria before approval. Providers should document absence of infection, fracture gap measurement, stability of fixation, prior treatments, and relevant comorbidities or risk factors.

Confirm bone is not infected.
Document that the two bone fragments are separated by less than 1 cm.
Document stability at both ends via appropriate fracture care/immobilization or fixation.
Provide history of prior surgery or treatments and time elapsed (e.g., ≥90 days for noninvasive nonunion).
List risk factors (e.g., alcoholism, chemotherapy, diabetes, obesity, osteoporosis, renal disease, tobacco or steroid use) if invoking 'risk of delayed or nonunion' rationale.

Note

Medical Necessity Documentation

Use professional judgment when submitting requests. This policy is a guide to medical necessity determinations but does not guarantee payment. Decisions remain subject to member-specific benefits, coverage terms, exclusions, and limitations.

Complete clinical records, imaging, and justification should accompany PA requests.
Authorization decisions are based on clinical policy plus plan benefits and may require peer review.

Denial Risk

Triggers for Denial (Ultrasonic and Device-Level Exclusions)

Triggers for denial include use of ultrasonic stimulators concurrently with other noninvasive osteogenic stimulators, device- or indication-level exclusions, and indications explicitly listed as not medically necessary. Verify device type and indication against policy exclusions before requesting coverage.

Ultrasonic stimulators used with other noninvasive osteogenic stimulators — not medically necessary.
Ultrasonic stimulators for avascular necrosis of the femoral head, stress fractures, or tibial stress fractures — not medically necessary.
Ultrasonic stimulators for fresh fractures in locations other than distal radius, tibial diaphysis, scaphoid, or Jones (5th metatarsal) — not medically necessary.
Use of ultrasonic stimulators when the fracture gap exceeds 1 cm — not medically necessary.
Osteogenic devices are not medically necessary for nonunion fractures of the skull, vertebrae, or tumor-related fractures.
Preoperative use of ultrasonic stimulators for fractures requiring surgical intervention or fixation — not medically necessary.
Claims for devices excluded by member benefit plan (e.g., cosmetic or investigational exclusions) may be denied.

Denial Risk

Denial Triggers Tied to Benefits/Exclusions

Denials may also arise from benefit-level exclusions, member-specific limitations, or lack of required documentation. Providers should verify member coverage and exclusions and ensure submitted information aligns with coverage terms.

Coverage is subject to evidence of coverage/certificate of benefits; PA or medical necessity approval does not override contractual exclusions or limitations.
If a device or indication is labeled 'not medically necessary' in this policy, benefit-level denial is likely unless an exception applies.

Definitions and Device Types

Multilevel spinal fusion — policy definition

DefinitionMultilevel spinal fusion is defined in this policy as involving three or more vertebrae.

Context of useReferenced as an indication for adjunctive osteogenic stimulation following multilevel spinal fusion in both noninvasive and invasive device criteria.

Related timing/thresholdsUsed alongside elapsed time criteria for failed fusion indications (e.g., >=6 months for non-spine failed fusion; >=9 months for failed spinal fusion with invasive devices).

Types of osteogenic stimulators

Electrical stimulators — categoriesInvasive (implantable), semi-invasive, and noninvasive (capacitive coupling [CC], pulsed electromagnetic field [PEMF], combined electromagnetic field/CMFT).

Ultrasonic stimulatorsLow-Intensity Pulsed Ultrasound (LIPUS) — noninvasive device applied to skin using coupling gel to transmit ultrasound waves.

Delivery methodsInvasive/semiinvasive use implanted electrodes or cathode wires; noninvasive electrical uses external treatment coils and an external power supply.

Low-Intensity Pulsed Ultrasound (LIPUS)

Modality descriptionLow-Intensity Pulsed Ultrasound (LIPUS) is a therapeutic ultrasound modality delivered noninvasively to the fracture site via a skin-applied device and coupling gel to stimulate bone healing.

Evidence citedRecent studies from 2021–2022 are referenced in the policy (e.g., Murakami et al. 2021; Bawale et al. 2021; Palanisamy et al. 2022) evaluating LIPUS for fracture healing and nonunions.

Typical use caseDescribed as an adjunct to conventional management for fresh closed fractures at high risk for delayed healing or for nonunion in skeletally mature patients when imaging and clinical criteria are met.

Electromagnetic field stimulation

TechniqueElectromagnetic field stimulation (PEMF/CEMF) delivers time-varying electromagnetic fields via external coils to induce osteogenesis noninvasively.

Clinical evidenceThe policy cites a Cochrane systematic review (Griffin et al., 2011) evaluating electromagnetic field stimulation for delayed union or nonunion of long bone fractures.

Efficacy notesAvailable evidence supports PEMF/CEMF for stimulation of healing in long bone fracture nonunions, though reported effectiveness varies across studies and devices.

OpenPayer

Osteogenic Stimulation

Coverage Criteria for Osteogenic Stimulation

Coding and Supplies

Provider Requirements, Prior Authorization, and Documentation

Clinical Background

Definitions and Device Types

20974	Electrical stimulation to aid bone healing; noninvasive (nonoperative).
20975	Electrical stimulation to aid bone healing; invasive (operative).
20979	Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative).

E0747	Osteogenesis stimulator; electrical, noninvasive, other than spinal applications.
E0748	Osteogenesis stimulator; electrical, noninvasive, spinal applications.
E0749	Osteogenesis stimulator; electrical, surgically implanted.
E0760	Osteogenesis stimulator, low intensity ultrasound, noninvasive.