ModifiedColorado Rocky Mountain Health PlansPolicy CS037.T

Electrical and Ultrasonic Bone Growth Stimulators

This policy governs coverage and medical necessity criteria for electrical (invasive and non-invasive) and ultrasonic bone growth stimulators for members of Colorado Rocky Mountain Health Plans, specifying indications, exclusions, and applicable coding.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElectrical and Ultrasonic Bone Growth Stimulators

Policy CodePolicy CS037.T

Change TypeRevised criteria and added clarification on non-covered indications

Effective DateFeb 1, 2026

Next Review Date

Key ActionObtain prior authorization and submit required clinical documentation demonstrating the member meets the policy's medical necessity criteria for the specific device and indication.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for Ultrasonic Bone Growth Stimulators; replaced criterion requiring 'less than 6 months have passed since the date of most recent surgical operation' with 'less than 6 months have passed since the date of most recent surgical procedure'.

Added language clarifying invasive or non-invasive electrical bone growth stimulator is unproven and not medically necessary for treatment of indications not listed as proven and medically necessary (including stress fractures).

Removed content/language pertaining to the state of Louisiana.

2device types covered

3proven indications

4high-risk criteria examples

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82-84%LIPUS pooled heal rate

Class IIIFDA risk class

Coverage and Medical Necessity Criteria

Electrical bone growth stimulator for lumbar spinal fusion

Covered when ALL of the following are met:

Required for coverage

High-risk features (any one suffices): Previously failed fusion at the same site (minimum of 6 months since the last surgical procedure) OR spinal fusion performed or to be performed at more than one level during a single surgery OR comorbid conditions associated with compromised bone healing (e.g., diabetes, obesity, osteoporosis, current tobacco use) OR spondylolisthesis grade II or greater

Ultrasonic stimulator for nonunion of long bone fractures

Covered when ALL of the following are met:

All criteria must be met: Fracture gap <= 1 cm; radiographic persistent fracture line without bridging callus present for >= 3 months; fracture reduced and immobilized; less than 6 months have passed since the date of most recent surgical procedure; fracture is not pathological or associated with malignancy; radiographic evidence of skeletal maturity

Electrical stimulation for spinal fusion (NASS)

Covered when ALL of the following are met (per NASS recommendations):

Spinal fusion augmentation (NASS) - covered when ALL of the following are met

High-risk criteria (any one suffices): Undergoing spinal fusion of 2 or more motion segments (3 vertebrae) OR undergoing a revision spinal fusion OR smokers who cannot stop smoking in preparation for fusion OR comorbidities when undergoing primary lumbar fusion (diabetes; inflammatory arthritis requiring long-term corticosteroids; immunocompromised state; systemic vascular disease; osteopenia or osteoporosis) OR elderly or debilitated patients with high surgical risk.N/A
Derived from NASS guidance.

Electrical stimulation for acute spinal fractures (conditional)

Considered on a conditional basis when ALL of the following are met:

Acute traumatic spinal fracture (conditional): Electrical stimulation may be considered as an adjunct for primary bone healing of acute traumatic spinal fractures in patients at high-risk for pseudarthrosis for a duration of 6 months, followed by CT to assess osseous union and dynamic imaging to confirm stability (translational displacement <= 2 mm and focal segmental angulation <= 5°).6 months; translational displacement <=2 mm; focal segmental angulation <=5°

Applies only when the patient meets the high-risk criteria listed in policy (see NASS high-risk criteria).

Ultrasonic Bone-Growth Stimulators (LIPUS/UBGS)

Summary of evidence and coverage stance:

UBGS - proven indication: Treatment of nonunion of long bone fractures (nonunion defined as persistent fracture line without bridging callus for >=3 months or as per study definitions) has supporting evidence from systematic reviews and meta-analyses reporting pooled heal rates ~82–84% for nonunions >=3 months; UBGS/LIPUS may be considered for documented long-bone nonunion when policy criteria are met.Nonunion commonly considered >=3 months (some analyses used >=8 months)

Evidence quality variable; favorable when used as alternative to surgery and when interval without surgery is <6 months in some reviews.

UBGS - unproven / not medically necessary: Use of UBGS (LIPUS) for all other indications (including fresh fractures at low or high risk of non-healing, stress fractures, and other non-listed indications) is considered unproven and not medically necessary outside of research or special arrangements.N/A

Consistent with NICE guidance and policy wording.

Coverage for electrical bone growth stimulators applied to spinal fusion is limited to use as an adjunct to lumbar spinal fusion in skeletally mature patients who have an increased risk for fusion failure. The policy specifies that one or more qualifying high-risk features must be documented (for example: previously failed fusion at the same site with at least six months since the last surgical procedure; fusion of more than one level as part of a single surgery; comorbid conditions that compromise bone healing such as diabetes, obesity, osteoporosis, or current tobacco use; or spondylolisthesis grade II or greater).

The policy excludes use of electrical stimulation for primary (index) spinal fusions without additional risk factors, and for fusions limited to a single motion segment (one-level fusion) when none of the listed high-risk criteria apply. Coverage is also not provided when malignancy or active infection is present. Prior authorization and required documentation (including imaging and surgical history) must be submitted to support the presence of qualifying high-risk features.

Electrical stimulation is not indicated for routine use in primary (index) spinal fusion procedures when the patient does not demonstrate any of the policy's specified high-risk features. Specifically, spinal fusion of a single motion segment (two vertebrae) without additional risk factors should not be augmented with an electrical bone growth stimulator.

For cases where high-risk criteria are present (for example multilevel fusion, revision fusion, inability to cease smoking, or comorbidities that impair bone healing), electrical stimulation may be considered if documentation demonstrates the patient meets the policy requirements and prior authorization is obtained.

Use of ultrasonic bone growth stimulators (low-intensity pulsed ultrasound) and electrical bone growth stimulators is limited to the indications listed as proven and medically necessary in this policy. For ultrasonic stimulators, the only proven indication covered is treatment of nonunion of long bone fractures when all policy criteria are satisfied (including fracture gap ≤ 1 cm, persistent fracture line ≥ 3 months, reduction and immobilization, less than 6 months since most recent surgical procedure when applicable, absence of pathologic fracture or malignancy, and radiographic evidence of skeletal maturity).

The policy follows evidence-based guidance and national recommendations (e.g., NICE and NASS) and therefore does not extend coverage to fresh fractures, stress fractures, or other unlisted indications outside of defined research or special arrangements.

Any application of invasive or non-invasive electrical stimulation or ultrasonic bone growth stimulators for indications not explicitly listed as proven and medically necessary in this policy is considered unproven and not medically necessary. Examples called out by the policy include treatment of stress fractures and fresh fractures outside the specified nonunion criteria.

Requests for such non-listed indications may be denied; providers should submit complete prior authorization documentation demonstrating that the patient meets the policy's listed criteria when coverage for a listed indication is sought.

Coding and Billing References

Covered CPT Codes (reference)CPT

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).

HCPCS CodesHCPCS

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.

FDA product codes (informational)mixed

LOE	stimulator, invasive bone growth
LOF	stimulator, bone growth, non-invasive
LPQ	ultrasound bone growth stimulators

Fracture gap — numeric threshold

Fracture gap threshold≤ 1 cm

ContextApplies to ultrasonic bone growth stimulator coverage for long bone nonunion

Documentation requiredRadiographic measurement demonstrating gap ≤ 1 cm

Radiographic persistent fracture line duration — numeric threshold

Radiographic persistence duration>= 3 months

Finding requiredPersistent fracture line without bridging callus present on radiographs

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for electrical and ultrasonic bone growth stimulators when seeking coverage for indications listed as proven/medically necessary in this policy. Submit the request to the plan's prior authorization unit before device acquisition or elective procedures that rely on device approval.

Prior authorization required for all invasive and non-invasive electrical bone growth stimulators used as an adjunct to spinal fusion.
Prior authorization required for ultrasonic (LIPUS) bone growth stimulators for treatment of long-bone nonunion.
Codes commonly requiring review: CPT 20974, 20975, 20979; HCPCS E0747, E0748, E0749, E0760.

Denial Risk

Denial for Non‑Covered Indications

The plan may deny requests when the device is requested for indications that are not listed as proven and medically necessary in this policy. Use for these indications is considered unproven or not medically necessary.

Key Definitions and Clinical Terms

Electrical Bone Growth Stimulator definition (invasive/external distinctions)

DefinitionA device that uses an electric field or current to stimulate bone growth; may be implanted (invasive) or applied externally (non-invasive)

Invasive (implantable)Implantable current generator surgically placed with electrode(s) at fusion site; device typically functional 6–9 months and removed in a second procedure

Non‑Invasive (external)External power source generates weak electrical currents using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields

Ultrasonic Bone Growth Stimulator definition

DefinitionA non‑invasive device that emits low‑intensity, pulsed ultrasound to accelerate bone repair; consists of an external power supply and treatment head centered over the fracture site

Application

Clinical Background and Evidence Summary

Bone healing is influenced by multiple determinants including fracture characteristics (type, gap size, and stability), local blood supply and soft tissue integrity, and patient factors such as age, nutritional status, smoking, and comorbidities (for example diabetes, osteoporosis, inflammatory disease, or immunocompromise).

Bone growth stimulators are intended to augment the biologic processes of repair by delivering targeted energy to the fracture or fusion site. Electrical bone growth stimulators may be either invasive (surgically implanted) or non-invasive (external) and deliver electrical fields or currents to stimulate osteogenesis. These devices are indicated only for skeletally mature patients and when the clinical and radiographic criteria in this policy are met.

Clinical decision-making should account for modifiable risk factors for impaired healing (e.g., smoking cessation, optimization of metabolic disease) and for the requirement to document radiographic and clinical elements specified in the policy when requesting prior authorization.

Policy Change Log

2026-04-01revision

Removed content/language pertaining to the state of Louisiana.

2026-02-01revisionLatest

Revised Ultrasonic Bone Growth Stimulator criteria replacing wording 'surgical operation' with 'surgical procedure' and added language clarifying electrical stimulators (invasive and non-invasive) are unproven and not medically necessary for indications not listed as proven (including stress fractures).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElectrical and Ultrasonic Bone Growth Stimulators

Policy CodePolicy CS037.T

Change TypeRevised criteria and added clarification on non-covered indications

Effective DateFeb 1, 2026

Next Review Date

Key ActionObtain prior authorization and submit required clinical documentation demonstrating the member meets the policy's medical necessity criteria for the specific device and indication.

SourceLink

On This Page

ApplicabilityCriterion for ultrasonic stimulator coverage of long-bone nonunion

Time since most recent surgical procedure for ultrasonic — numeric threshold

Maximum time since most recent surgical procedure< 6 months

ScopeRequired for ultrasonic bone growth stimulator coverage of long-bone nonunion

Policy wording noteRevised wording uses 'surgical procedure' (policy history)

Treatment of fresh fractures at low or high risk of non-healing (unless otherwise specified as covered).
Use for stress fractures.
Any indication not explicitly listed in the policy as proven and medically necessary, including off-label uses without supporting clinical evidence.
Primary (index) spinal fusions without additional high-risk factors for pseudarthrosis (see clinical criteria).

Documentation Required

Required Documentation

Provide complete medical records and relevant documentation with prior authorization requests and upon request for review. Failure to submit requested records may result in denial or delay.

Condition requiring procedure and clinical indication.
Physician's treatment plan describing intended use of device and expected duration.
Relevant surgical history, including dates and description of prior spinal fusion(s) or fracture surgeries.
Details of prior treatments tried, failed, or contraindicated (include dates, duration, and reason for discontinuation).
Documentation of comorbid conditions that may compromise bone healing (e.g., diabetes, obesity, osteoporosis, current tobacco use).

Documentation Required

Required Documentation for Review

For review of requests, submit pertinent imaging and clinical history elements to support diagnosis and device appropriateness. Imaging should clearly document fracture or fusion status and relevant measurements.

Detailed relevant imaging reports, including evidence of skeletal maturity.
For spinal indications: presence or absence of spondylolisthesis; if present, include grade.
For ultrasonic therapy of nonunion: size of fracture gap (cm) and radiographic evidence of a persistent fracture line without bridging callus; indicate duration of nonunion (months).
For electrical stimulators adjunct to fusion: date(s) and site(s) of previous spinal fusion surgery(ies) and number of vertebral levels fused.
Clinical history showing immobilization/reduction of fracture, and timing relative to most recent surgical procedure (e.g., <6 months or ≥6 months as applicable).

Note

Evidence‑Informed Sequencing Considerations

When considering LIPUS versus surgery for nonunion, use evidence‑informed sequencing: LIPUS can be considered for established nonunions of long bones with gap ≤1 cm and fracture age ≥3 months (more favorable if ≥8 months), particularly when surgical intervention is undesirable or contraindicated. Favorable results have been observed when an interval without surgery of less than 6 months precedes LIPUS; patients with small gap sizes and low nonunion severity scores are more likely to benefit. Choose surgical management when gap >1 cm, active infection, pathological fracture, presence of malignancy, or other factors predicting LIPUS failure.

Consider LIPUS when fracture gap ≤1 cm and radiographic nonunion persists ≥3 months (stronger evidence if ≥8 months).
Prefer LIPUS as alternative to surgery in patients with low NUSS/nonunion severity and small gap size.
An interval without surgery of <6 months prior to initiating LIPUS was associated with more favorable outcomes in pooled analyses; document prior surgical timing.
Do not use LIPUS when gap >1 cm, pathological fractures, active infection, or malignancy are present — consider surgical alternatives.
For spinal fusion, reserve electrical stimulators for patients at increased risk for pseudarthrosis (see policy criteria) and do not use routinely for primary fusions without risk factors.

Used externally and programmed to promote accelerated fracture healing

Indication noteCovered for treatment of long‑bone nonunion when all specified criteria are met

Nonunion Fracture definition

DefinitionAn arrest in the healing process defined by: motion at the fracture site; persistent fracture line without bridging callus on radiographs; and incomplete progression toward radiographic healing in expected time with further healing not expected

Diagnostic evidenceRadiographs showing persistent fracture line without bridging callus and clinical evidence of non‑progression

ContextUsed as the coverage indication for ultrasonic bone growth stimulators when criteria (including duration ≥3 months) are met

Skeletally mature definition

DefinitionState when growth plates have fused and all bone growth is complete

Radiographic evidenceEvidence of closed/fused epiphyses on imaging is required for device indications

ApplicabilityBone growth stimulators are indicated only for skeletally mature individuals

High-risk patient criteria list

SmokingCurrent smokers who cannot stop smoking prior to fusion (e.g., due to underlying condition)

DiabetesDiabetes mellitus as a comorbidity increasing risk of nonunion/pseudarthrosis

Long‑term corticosteroid therapyInflammatory arthritis requiring long‑term corticosteroids

Immunocompromised stateExamples include chemotherapy/radiation to the spine, hypogammaglobulinemia, granulocytopenia, AIDS

Vascular disease / poor perfusionSystemic vascular disease or conditions causing diminished blood flow

Osteopenia / OsteoporosisLow bone density predisposing to impaired healing

Multilevel or revision fusion / elderly debilitatedMultilevel fusion or revision fusion, elderly or debilitated patients at high surgical risk

Acute spinal fracture definition / examples as per NASS conditional recommendation

Definition / examplesAcute traumatic spinal fractures with ≥50% loss of vertebral height, segmental angulation 5–15°, and stable translational deformity on dynamic imaging without neurologic deficits

Other included conditionsSymptomatic acute spondylolysis (with or without radiculopathy) and acute osteoporotic compression fractures with >6 weeks of pain without neurologic deficits, excluding pathologic fracture

NASS conditional recommendation detailsElectrical stimulation considered for 6 months followed by CT to assess osseous union and dynamic imaging to confirm stability