CurrentCentenePolicy CP MP.194

Clinical Policy: Osteogenic Stimulation

Defines medical necessity criteria for noninvasive electrical, invasive electrical (implantable), and low-intensity pulsed ultrasound (LIPUS/ultrasonic) osteogenic stimulators for fracture nonunion, delayed union, selected fresh fractures at high risk, and as adjuncts to spinal fusion. Also lists non-covered/ not medically necessary indications and coding implications.

Policy Summary

PayerCentene

PolicyClinical Policy: Osteogenic Stimulation

Policy CodePolicy CP MP.194

Change TypeCriteria reformatting; coding update

Effective DateJun 1, 2025

Next Review Date

Key ActionProvide at least two sets of imaging (multiple views) separated by a minimum of 90 days showing fracture healing has ceased prior to initiating electrical or ultrasonic osteogenic stimulation.

POLICY UPDATE CHANGES

06/25 revision updated criteria formatting and moved/renumbered criteria without impact to clinical criteria; references reviewed and updated.

Added HCPCS code E0760 to coding implications in prior revisions (historical).

3Device categories covered (noninvasive electrical, invasive electrical, ultrasonic)

>=90Minimum interval before nonunion treatment (days)

1 cmMaximum fracture gap allowed for coverage

9Minimum interval for failed spinal fusion (months)