CurrentBlue Cross Blue Shield - MassachusettsPolicy 499

Electrical Bone Growth Stimulation (Appendicular Skeleton)

Policy governs use of electrical bone growth stimulators (noninvasive, semi‑invasive, implantable) for fracture nonunions, delayed unions, fresh fractures, stress fractures, congenital pseudarthrosis, and adjunctive post‑surgical use in the appendicular skeleton for BCBSMA members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyElectrical Bone Growth Stimulation (Appendicular Skeleton)

Policy CodePolicy 499

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient services and document medical necessity with serial radiographs demonstrating lack of progressive healing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 cmmaximum fracture gap for nonunion coverage

3 monthsminimum timeframe used to define lack of progression

6-9 monthstypical implantable generator duration

6-8 hrs/dayPEMF daily wear time

Annual 2019-2025

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.

policy review cadence

Coverage Criteria for Electrical Bone Growth Stimulation

Fracture Nonunion (Noninvasive stimulation)

Covered when ALL of the following are met

Fracture nonunion coverage criteria: Serial radiographs have confirmed that no progressive signs of healing have occurred; At least 3 months have passed since the date of fracture; The fracture gap is 1 cm or less; The individual is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities; The individual can be adequately immobilized.

Not sufficiently supported / Investigational indications

Coverage evaluation by indication

Indications with insufficient evidence: Delayed union; Fresh fractures; Stress fractures; Immediate post‑surgical treatment after appendicular skeletal surgery; Arthrodesis or failed arthrodesis; Implantable and semi‑invasive stimulators for appendicular skeleton indications.

Evidence is insufficient or investigational for these uses.

Coverage summary (evidence insufficient conclusions)

Coverage stance summarized from evidence review in this document segment:

Noninvasive for stress fractures: Evidence includes an RCT that found increased hours of device use associated with reduced time to healing, but no difference in healing rate between treatment and placebo; evidence is insufficient to determine effects on health outcomes.

Refer to full policy for any specific coverage criteria.

Noninvasive for post‑operative appendicular skeleton: Evidence includes 2 small RCTs; one trial suggested decreased time to union but clinical outcomes were not assessed; evidence is insufficient to determine effects on health outcomes.

Refer to full policy for any specific coverage criteria.

Implantable and semi‑invasive stimulation: Evidence consists of a small number of case series for fracture, pseudarthrosis, or post‑operative appendicular skeleton; evidence is insufficient to determine improvement in net health outcome.

Implantable and semi‑invasive electrical bone growth stimulators are considered investigational for use in fracture, pseudarthrosis, or post‑surgical applications in the appendicular skeleton. The source evidence consists primarily of a small number of case series and is judged to be insufficient to demonstrate improvement in net health outcome for these indications.

This policy does not list additional explicit exclusions by code or setting; however, indications for which the evidence is described as insufficient or investigational (for example, delayed union, fresh fractures, stress fractures, immediate post‑surgical appendicular skeleton treatment, and implantable or semi‑invasive stimulators) may effectively be treated as non‑covered without stronger supporting data.

The evidence supports noninvasive electrical bone growth stimulation for fracture nonunions, but for other uses — including delayed union, fresh fractures, stress fractures, and immediate post‑surgical therapy of the appendicular skeleton — randomized controlled trials are limited or show no consistent benefit. Thus, the available data were judged insufficient to establish effectiveness of noninvasive stimulation for these indications.

Across indications the systematic review of the evidence found results to be limited in size and quality. For several clinical situations (delayed union, fresh fractures, stress fractures, post‑operative adjunctive use, and implantable/semi‑invasive devices) the evidence was described as insufficient to determine whether electrical or electromagnetic stimulation improves health outcomes; consequently, these uses are characterized as not supported or investigational in the policy.

Coding and Billing Codes

CPT CodesCPT

20974
20975

HCPCS CodesHCPCS

E0747	Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
E0749	Osteogenesis stimulator, electrical, surgically implanted

Fracture gap — maximum for nonunion coverage

Maximum fracture gap1 cm or less

Requirement sourceFracture nonunion coverage criteria in policy text

Applicable settingAppendicular skeleton fractures considered for noninvasive stimulation

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required for inpatient services; outpatient prior authorization requirements vary by product. Check the member's product: some outpatient services may require prior authorization while others (e.g., certain Commercial PPO and Indemnity products) do not.

Inpatient services: precertification/preauthorization required.
Outpatient services: prior authorization requirements vary by product; verify member contract and product-specific rules.

Documentation Required

Documentation and Medical Necessity Requirements

The above medical necessity criteria MUST be met and documented for coverage. Providers should document the indication, duration of non-healing, radiographic evidence, prior conservative treatments, ability to immobilize, and any relevant risk factors. Report services using current procedure and diagnosis codes.

Background and Scope

Electrical and electromagnetic stimulation approaches include noninvasive devices (external coils or skin pads), semi‑invasive systems (percutaneous electrodes with external power), and implantable generators with electrodes. These technologies have been applied to promote healing in delayed and nonunion fractures of the appendicular skeleton. FDA approval exists for noninvasive stimulation in fracture nonunions and congenital pseudarthrosis based largely on pre‑post and small randomized studies, while the evidence base for implantable and semi‑invasive devices is limited to case series.

Definitions

Fracture nonunion — definition

DefinitionFailure of progression of fracture healing for at least 3 consecutive months (and for at least 6 months following the fracture) or lack of progressive signs of healing

Supporting noteFDA labeling historically used 9 months with 3 months of no progression; policy adopts 3-month lack of progression consistent with clinical literature

Clinical featuresMay be accompanied by symptoms such as pain or difficulty bearing weight

Delayed union — definition

DefinitionA decelerating healing process on serial radiographs with lack of clinical and radiologic evidence of union for no less than 3 months from the index injury or most recent intervention

Relation to nonunion

Policy Revision History

2025-06annual_reviewLatest

Annual policy review — description and references updated; policy statements unchanged; prior authorization references maintained in policy history.

2024-06annual_review

Annual policy review — references updated; policy statements unchanged; prior authorization references noted in policy history.

2023-06annual_review

Annual policy review — minor editorial refinements to policy statements; intent unchanged; prior authorization references included in policy history.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyElectrical Bone Growth Stimulation (Appendicular Skeleton)

Policy CodePolicy 499

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient services and document medical necessity with serial radiographs demonstrating lack of progressive healing.

SourceLink

On This Page

Document serial radiographs confirming lack of progressive healing.

Document that at least 3 months have passed since the date of fracture (or definition used per policy).

Document fracture gap ≤ 1 cm and patient’s ability to comply with immobilization/non–weight bearing as applicable.

Include prior treatments attempted and clinical symptoms (pain, difficulty bearing weight).

Use most up-to-date CPT/HCPCS/ICD codes and modifiers when billing.

Denial Risk

Denial Risk for Insufficient Evidence

Therapies and indications with insufficient evidence carry a higher risk of denial. Examples include use of noninvasive electrical bone growth stimulation for stress fractures, immediate post‑operative appendicular use, and implantable or semi‑invasive devices for fractures or post‑operative appendicular cases.

Noninvasive stimulation for stress fractures: evidence insufficient — denial possible.
Immediate post‑operative appendicular use: evidence insufficient — denial possible.
Implantable and semi‑invasive stimulators: considered investigational — denial likely.

Note

Management of Delayed Unions

Individuals with recognized delayed fracture unions may begin by reducing risk factors and attempting conservative management; if the delayed union persists, patients may progress to surgical repair.

Initial actions: reduce modifiable risk factors, ensure adequate immobilization, and document conservative measures and their duration.
If no progression of healing after appropriate conservative management and criteria for nonunion are met, consider surgical repair and document rationale.

When delayed union and nonunion are considered together they are sometimes called 'ununited fractures'

Distinguishing featureDelayed union shows some deceleration in healing, whereas nonunion shows no evidence of healing on serial radiographs

Device types — noninvasive, invasive, semi‑invasive

Noninvasive devicesExternal coils (pulsed electromagnetic fields) or skin pads (capacitive coupling) delivering stimulation without surgical implantation

Invasive (implantable) devicesSurgically implanted generator with electrodes placed within bone fragments; generator typically functions 6–9 months

Semi‑invasive devicesPercutaneous electrodes with an external power supply (no implanted generator removal needed)

Implantable / semi‑invasive stimulation — label and short definition

LabelImplantable and semi‑invasive electrical bone growth stimulation

Short definitionDevices requiring surgical implantation of a generator and implanted electrodes (implantable) or percutaneous electrodes with external power (semi‑invasive); evidence base largely from case series

Typical generator durationImplantable generator typically remains functional for 6–9 months

Noninvasive stimulation — label and short definition

LabelNoninvasive electrical bone growth stimulation

Short definitionExternal devices that generate electrical currents at the target site via pulsed electromagnetic fields, capacitive coupling (skin pads), or combined magnetic fields; worn externally for defined daily durations

Typical wear timesPulsed electromagnetic fields: 6–8 hours/day for 3–6 months; capacitive coupling: may be worn up to 24 hours/day or up to 9 months

2022-06annual_review

Annual policy review — description, summary, and references updated; policy statements unchanged; prior authorization referenced in policy history.

2021-05annual_review

Annual policy review — description, summary, and references updated; policy statements unchanged; prior authorization references present in historical entries.

2021-01administrative_update

Medicare information removed (see MP #132); coding clarification entries appear elsewhere in history.

2020-06annual_review

Annual policy review — pseudarthrosis added to the policy; other statements unchanged; prior authorization referenced in policy history.

2019-05annual_review

Annual policy review — description, summary, and references updated; policy statements unchanged; prior authorization references included.