Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)Mass General Brigham Bone Growth Coverage | OpenPa…
    Ask Trek AI about this page
    CurrentMass General Brigham Health PlanPolicy 009

    Bone Growth Stimulators

    Customize your policy alerts

    Sign up for Mass General Brigham Health Plan Policy 009 alerts

    Get alerted when Policy 009 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs medical-necessity determinations and prior authorization for bone growth stimulation, including noninvasive electrical and low-intensity ultrasound devices, across Medicare Advantage, Mass General Brigham ACO, One Care and SCO, Commercial, and Qualified Health Plan members.

    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyBone Growth Stimulators
    Policy CodePolicy 009
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateDecember 1, 2026
    Last ReviewDec 1, 202623d
    Next Review DateNot specified
    Key ActionObtain prior authorization and submit documentation supporting the applicable medical-necessity criteria before requesting bone growth stimulation.
    SourceLink
    POLICY UPDATE CHANGES

    The December 1, 2026 ad hoc review updated the Mass General Brigham ACO section.

    YesPrior authorization required
    3Listed code categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2
    Noninvasive modalities
    Invasive devicesNot covered

    Coverage Criteria

    Commercial and Qualified Health Plan criteria

    Covered when ALL of the following are met:

    Commercial/QHP medical necessity: The request must satisfy InterQual® criteria in CP:Durable Medical Equipment, Bone Growth Stimulators, Noninvasive.

    The policy does not reproduce the InterQual criteria. Providers must access the InterQual Criteria Lookup Tool through the Mass General Brigham Health Plan Provider website.

    General coverage conditions

    Covered when ALL of the following are met:

    General noninvasive coverage conditions: The requested bone growth stimulation must be a covered noninvasive type, be recommended by the member’s primary care provider or referring specialist, and meet the applicable medical-necessity criteria.

    Covered noninvasive types include electrical bone growth stimulation and low-intensity ultrasound bone growth stimulation. The policy does not specify the underlying clinical thresholds in this document.

    Medicare and One Care/SCO criteria

    Medical-necessity determinations are made using the applicable coverage pathway:

    CMS-based criteria: Apply the applicable CMS National Coverage Determinations, Local Coverage Determinations, Local Coverage Articles, and Medicare-manual documentation for osteogenic stimulators. For One Care and SCO members, if Medicare criteria are not met, apply MassHealth medical-necessity criteria.

    The policy identifies NCD 150.2, LCD L33796, and Article A52513 as relevant Medicare guidance.

    Invasive electrical bone growth stimulators are not covered by Mass General Brigham Health Plan.

    Authorized Codes

    Authorized Code — procedure codes listedCPT
    20974Electrical stimulation to aid bone healing; noninvasive (nonoperative)
    20979Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
    Authorized Code — DME codes listedHCPCS
    E0747Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
    E0748Osteogenesis stimulator, electrical, noninvasive, spinal applications
    E0760Osteogenesis stimulator, low intensity ultrasound, noninvasive

    Authorization and Decision Requirements

    Prior Authorization

    Medicare Advantage Prior Authorization Required

    Prior authorization is required for bone growth stimulators for Medicare Advantage members. Mass General Brigham Health Plan uses CMS guidance to determine medical necessity, including applicable NCDs, LCDs, LCAs, and Medicare-manual documentation; when CMS provides no guidance, the Plan’s medical policies apply.

    • CMS NCD 150.2 — Osteogenic Stimulators
    • CMS LCD L33796 — Osteogenesis Stimulators
    • CMS Article A52513 — Osteogenesis Stimulators Policy Article
    Prior Authorization

    ACO Prior Authorization Required

    Prior authorization is required for Mass General Brigham ACO members. MassHealth guidance is used first; when MassHealth has no guidance for the requested DME, refer to the applicable Medicare Advantage LCD, and if no relevant LCD exists, use the Commercial and Qualified Health Plans criteria.

    • MassHealth guidance is the primary source when available.

    Policy Background

    Bone growth stimulators are used to support bone healing through electrical stimulation or low-intensity ultrasound. This policy describes the guidelines used to determine medical appropriateness for bone growth stimulation and requires prior authorization for its use.

    Device Definitions

    Noninvasive electrical bone growth stimulation
    ModalityElectrical stimulation
    PurposeTo aid bone healing
    Operative statusNoninvasive (nonoperative)
    Low-intensity ultrasound bone growth stimulation
    ModalityLow-intensity ultrasound stimulation
    PurposeTo aid bone healing
    Operative statusNoninvasive (nonoperative)

    Medical-Necessity Criteria

    Noninvasive bone growth stimulator

    Covered when ALL of the following are met:

    DME medical necessity: The requested bone growth stimulator must be a covered noninvasive type, meet the applicable plan-specific medical-necessity criteria, and be recommended by the member’s primary care provider or referring specialist.

    Commercial and Qualified Health Plan criteria are determined using InterQual® criteria. Other product lines follow the CMS or MassHealth pathways described in the policy.

    Required Documentation

    Documentation Required

    Submit medical-necessity documentation

    Submit documentation supporting the applicable medical-necessity criteria and the requested bone growth stimulation service. Identify the recommendation by the member’s primary care provider or referring specialist.

    • Document that the requested bone growth stimulator is a covered noninvasive type.
    • Include information supporting the applicable plan-specific medical-necessity criteria.
    Documentation Required

    Provide plan-specific documentation

    Provide plan-specific supporting documentation based on the member’s product line and determination pathway. Use applicable CMS, MassHealth, or Medicare-manual documentation requirements.

    • Medicare Advantage: use applicable CMS NCDs, LCDs, LCAs, and Medicare-manual documentation.
    • One Care and SCO: apply CMS documentation requirements first and MassHealth requirements when Medicare criteria are not met.

    Excluded Services

    Invasive electrical bone growth stimulators are not covered by Mass General Brigham Health Plan.

    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyBone Growth Stimulators
    Policy CodePolicy 009
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateDecember 1, 2026
    Last ReviewDec 1, 202623d
    Next Review DateNot specified
    Key ActionObtain prior authorization and submit documentation supporting the applicable medical-necessity criteria before requesting bone growth stimulation.
    SourceLink
    On This Page
    Coverage CriteriaAuthorized CodesAuthorization and Decision RequirementsPolicy BackgroundDevice DefinitionsMedical-Necessity CriteriaRequired DocumentationExcluded Services
  1. Use the relevant Medicare Advantage LCD when MassHealth has no specific DME guidance.
  2. If no relevant LCD exists, refer to Commercial and Qualified Health Plans medical-necessity information.
    3. Prior Authorization

    One Care and SCO Prior Authorization Required

    Prior authorization is required for One Care and Senior Care Options (SCO) members. CMS NCDs, LCDs, LCAs, and Medicare-manual documentation provide the initial criteria; when CMS guidance is unavailable or the member does not meet all Medicare criteria, MassHealth criteria apply.

    • Apply Medicare Advantage criteria and exclusions first.
    • If Medicare Advantage criteria are not met, apply MassHealth criteria.
    Prior Authorization

    Commercial and QHP Prior Authorization Required

    Prior authorization is required for Commercial and Qualified Health Plan members. Medical necessity is determined through InterQual® criteria in CP: Durable Medical Equipment, Bone Growth Stimulators, Noninvasive; CPT codes 20974 and 20979 are covered when the same criteria are met.

    • Access the InterQual® Criteria Lookup Tool through the Mass General Brigham Health Plan Provider website.
    • The request must meet applicable medical-necessity criteria and be recommended by the member’s primary care provider or referring specialist.
    Documentation Required

    Medical-Necessity Documentation

    Submit documentation demonstrating medical necessity under the applicable plan criteria and supporting the specific bone growth stimulator requested. For Commercial and QHP requests, document the referring provider’s recommendation and satisfaction of the applicable InterQual® criteria.

    • Include clinical documentation supporting the requested device and applicable medical-necessity criteria.
    • For Medicare Advantage, use documentation requirements in applicable CMS NCDs, LCDs, LCAs, and Medicare manuals.
    • For One Care and SCO, provide documentation supporting the applicable Medicare criteria or, when required, MassHealth criteria.
    Documentation Required

    Plan-Specific Supporting Documentation

    Use the documentation sources required by the member’s plan when submitting the authorization request. Medicare Advantage and One Care/SCO determinations rely on CMS coverage guidance and Medicare-manual documentation, while ACO requests follow the applicable MassHealth-to-Medicare hierarchy.

    • Medicare Advantage: CMS NCDs, LCDs, LCAs, and Medicare manuals; use Plan medical policies when CMS has no guidance.
    • ACO: MassHealth guidance first; then the relevant Medicare Advantage LCD; then Commercial and QHP information if no LCD exists.
    • One Care/SCO: CMS guidance first; if unavailable or criteria are not met, apply MassHealth criteria.

    Unsupported block type: denial_risk

    Denial Risk

    Missing Prior Authorization May Result in Denial

    Bone growth stimulator requests submitted without required prior authorization may be denied. Confirm the member’s plan and obtain authorization before providing or billing for the requested service.

    • Prior authorization is required for Medicare Advantage, Mass General Brigham ACO, One Care, SCO, Commercial, and Qualified Health Plan members.
    • Coverage is subject to the applicable plan-specific medical-necessity criteria.
    Denial Risk

    Criteria Not Met May Result in Denial

    A request may be denied when the member does not satisfy the applicable medical-necessity criteria. For One Care and SCO, MassHealth criteria apply when CMS guidance is unavailable or Medicare criteria are not met; Commercial and QHP requests must meet InterQual® criteria.

    • ACO requests follow the MassHealth, Medicare Advantage LCD, and Commercial/QHP hierarchy when applicable.
    • One Care and SCO requests must meet Medicare criteria or, when required, MassHealth criteria.
    • Commercial and QHP requests must meet InterQual® criteria for noninvasive bone growth stimulators, including when CPT 20974 or 20979 is requested.
  3. ACO: use MassHealth guidance when available, with the policy’s Medicare and Commercial/QHP fallback pathways when applicable.