DraftHighmark DelawarePolicy N/A

Osteogenic Stimulators (Ultrasonic and Electrical)

Forms and medical necessity documentation for ultrasonic and electrical osteogenic stimulators for spinal and non‑spinal indications; intended for providers requesting device coverage for Highmark Delaware members.

Policy Summary

PayerHighmark Delaware

PolicyOsteogenic Stimulators (Ultrasonic and Electrical)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Certificate of Medical Necessity with the device‑specific fields and supporting documentation (typed office note, recent X‑ray date, fracture/fusion dates, and physician signature).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4document chunks/pages provided

3device pathways/forms

Y/N/Dresponse format

Coverage and Medical Necessity Criteria

Ultrasonic Non‑spinal (E0760) Medical Necessity

Covered when ALL of the following are documented:

Ultrasonic non‑spinal criteria: Patient has a nonunion of a long‑bone fracture; date of fracture and date of recent X‑ray provided; absence of fracture healing documented on recent imaging (or if a FRESH fracture, documentation of prior treatment and rationale for ultrasonic stimulator use); statement whether other stimulators are currently in use for the same problem.

Based on CMN fields in chunk 2.

Electrical Non‑spinal (20974/20975/E0747) Medical Necessity

Covered when ALL of the following are documented:

Electrical non‑spinal criteria: Patient has a nonunion of a long‑bone fracture or failed fusion of a joint other than the spine; presence/absence of congenital pseudoarthrosis documented; date of fracture or fusion and date of recent X‑ray provided; absence of fracture or fusion healing documented on recent imaging.

Based on CMN fields in chunk 3.

Policy Summary

PayerHighmark Delaware

PolicyOsteogenic Stimulators (Ultrasonic and Electrical)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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.

Provider Requirements and Submission Guidance

Prior Authorization

CMN completion tied to device codes

Prior authorization requires completion of the Certificate of Medical Necessity (CMN) fields that correspond to the requested device code. Ensure the CMN is completed fully for the device type (Ultrasonic non‑spinal E0760; Electrical non‑spinal 20974/20975/E0747; Electrical spinal E0748/20975). Incomplete CMNs tied to device codes may delay review or lead to denial.

Complete CMN sections specific to the device code being requested (E0760, E0747, E0748, 20974/20975).
Include dates requested on CMN: fracture/fusion date and date of most recent X‑ray.

Denial Risk

Spinal fusion healing not documented

For spinal fusion requests, objective radiological documentation of fusion status is required. If fusion healing (or lack thereof) is not documented by objective radiographic criteria (e.g., evidence of pseudoarthrosis), the request may be denied.

Provide the date of spinal fusion and number of levels fused on the CMN.
Document whether recent fusion has failed to heal by objective radiological criteria and prior failed fusion at the same site, if applicable.

Documentation Required

Imaging and treatment history

Include recent imaging dates and the treatment history leading up to the request. The CMN should list the date of the most recent X‑ray and the date of fracture or fusion, and state whether there has been evidence of healing.

Date of fracture or fusion and date of recent X‑ray must be provided.
State whether there has been evidence of fracture or fusion healing (Yes/No/Does not apply).
For nonunion or failed fusion, include imaging evidence supporting diagnosis.

Documentation Required

Authentication

The CMN and accompanying office note must be authenticated by the requesting physician. A handwritten or electronic signature by the physician is required; physician signature stamps are not acceptable. Provide a contact name and phone number on the CMN.

Physician signature (stamps not acceptable) and date on CMN.
Include contact name and phone number on CMN and requesting provider information in the typed office note.

Documentation Required

Conservative treatment documentation for fresh fractures

For fresh fractures, document prior conservative treatment and the clinical rationale for requesting a stimulator. The CMN must explain what conservative care was provided and why an ultrasonic or electrical stimulator is being requested instead of continued conservative management.

If a FRESH fracture, describe prior treatment provided and explain rationale for stimulator request.
Document whether other stimulators are currently in use for the same problem.

Background

Osteogenic stimulators—both ultrasonic and electrical—are intended to promote bone healing in settings such as long‑bone nonunions, failed joint fusions outside the spine, and spinal pseudoarthrosis. The CMN forms distinguish indications and documentation by pathway: the ultrasonic (E0760) form focuses on non‑spinal long‑bone nonunion and asks for fracture date, recent X‑ray date, evidence of healing, prior treatment for fresh fractures, and concurrent stimulator use; the electrical non‑spinal (20974/20975/E0747) form captures nonunion, failed non‑spinal fusion, congenital pseudoarthrosis, and imaging dates; the electrical spinal (E0748/20975) form requests fusion date, number of levels fused, objective radiographic evidence of pseudoarthrosis, and prior failed fusion at the same site. Device selection and coverage are driven by these documented findings.

Definitions

Nonunion (long-bone fracture)

DefinitionNonunion: a long-bone fracture that has failed to demonstrate radiographic healing.

Required documentationAffirmation that the patient has a nonunion of a long-bone fracture (CMN question 1).

Imaging requirementDate of fracture and date of recent X-ray must be provided; absence of fracture healing must be documented on recent imaging (CMN questions 2–4).

Fresh fracture pathIf a fresh fracture, document prior treatment and rationale for ultrasonic stimulator request (CMN question 5).

Concurrent devicesState whether any other stimulators are currently in use for the same problem (CMN question 6).

Pseudoarthrosis (spinal)

DefinitionPseudoarthrosis (spinal): failed spinal fusion identified by objective radiological criteria.

Required documentationDate of spinal fusion and number of fused levels must be provided (CMN questions 1–2).

Radiographic criteriaExplicit documentation that recent fusion has failed to heal (pseudoarthrosis) by objective radiological criteria is required (CMN question 3).

Prior surgeryIndicate whether the patient has had a prior failed spinal fusion at the same site (CMN question 4).

OpenPayer

Osteogenic Stimulators (Ultrasonic and Electrical)

Coverage and Medical Necessity Criteria

Relevant Billing Codes

Provider Requirements and Submission Guidance

Background

Definitions

20974	Electrical - Non-spinal (code listed)
20975	Electrical - Non-spinal / spinal (code listed)
E0747	Electrical - Non-spinal

E0748	Electrical - Spinal
20975	Electrical - Spinal (code listed)