Bone Growth Stimulators - Electric
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Policy governing coverage and prior authorization requirements for electrical bone growth stimulators (non-invasive, semi-invasive, and invasive) for Moda Health members, including spinal and non-spinal indications and related documentation requirements.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Non-invasive (non-spinal) coverage
Covered when ANY of the following are met (non-invasive, non-spinal E0747):
Non-invasive non-spinal indications
- Fracture nonunion subcriteria: i. Fracture location: long bone (bones of the shoulder girdle, upper and lower extremities), scaphoid, or navicular; ii. At least 3 months have passed since the date of fracture; iii. Serial radiographs at least 3 months apart have confirmed that no progressive signs of healing have occurred; iv. The fracture gap is ≤1 cm; v. The patient can be adequately immobilized and is likely to comply with non-weight bearing.
Non-invasive (spinal) coverage
Covered for skeletally mature individuals as adjunct to spinal fusion when ANY one of the following risk factors for fusion failure is present:
Invasive (spinal) coverage
Invasive electrical bone growth stimulators covered for skeletally mature individuals as adjunct to spinal fusion when ANY one of the following are met:
Invasive adjunct for major long bone non-union
Covered when used as adjunct to surgical treatment of non-union of a major long bone for skeletally mature individuals:
Electrical bone growth stimulation is considered investigational when used for the following indications: fresh fractures, delayed unions, avascular necrosis, stress fractures, and sacroiliac fusion.
Coverage and claims for electrical bone growth stimulators must comply with applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) where relevant. Providers should follow the cited CMS resources (for example, Noridian LCD L33796) and note that additional indications may be covered at the discretion of the health plan.
Use of electrical bone growth stimulation for the indications listed as investigational in this policy is not supported and therefore not covered.
Coding, Diagnosis, and Coding-Related Criteria
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) |
| 20975 | Electrical stimulation to aid bone healing; invasive (operative) |
| 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, non-invasive |
| M43.00 | Spondylolysis, site unspecified |
| M43.10 | Spondylolisthesis, site unspecified |
| Q76.2 | Congenital spondylolisthesis |
| M43.00 | Spondylolysis, site unspecified |
| M43.10 | Spondylolisthesis, site unspecified |
| Q76.2 | Congenital spondylolisthesis |
| S02.91XK | Unspecified fracture of skull, subsequent encounter for fracture with nonunion |
| S02.92XK | Unspecified fracture of facial bones, subsequent encounter for fracture with nonunion |
| S12.000K | Unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with nonunion |
| S12.001K | Unspecified nondisplaced fracture of first cervical vertebra, subsequent encounter for fracture with nonunion |
| S12.100K | Unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with nonunion |
| S12.101K | Unspecified nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with nonunion |
| S12.200K | Unspecified displaced fracture of third cervical vertebra, subsequent encounter for fracture with nonunion |
| L33796 | Noridian Local Coverage Determination (LCD) for Osteogenesis Stimulators |
Prior Authorization, Documentation, and Billing Guidance
Prior authorization required with supporting chart documentation
Prior authorization is required for osteogenesis stimulators (non-invasive and invasive). The prior authorization request must include required documentation (chart notes, treatment history, and serial x-ray reports) and the specific device CPT/HCPCS codes should be supported by meeting the policy coverage criteria for the applicable device (non‑invasive E0747/E0748; invasive E0749, 20975/20974).
- Include chart notes documenting original injury and current medical status.
- Include treatment history.
- Include serial X‑ray reports.
Follow applicable NCD/LCD (e.g., Noridian LCD L33796)
Follow applicable Medicare NCDs/LCDs where relevant; coverage and prior authorization may also be subject to plan discretion and the referenced Noridian LCD L33796.
- Providers should consult CMS coverage resources and Noridian LCD L33796 when Medicare rules apply.
Step therapy: Not applicable / no step therapy specified
No step therapy requirements are specified in this policy section.
Required documentation to support prior authorization
When submitting a prior authorization request, include chart notes from the treating physician documenting the original injury and current medical status, a complete treatment history, and serial x‑ray reports demonstrating the imaging timeline and findings.
- Chart notes showing documentation of original injury and current medical status.
- Treatment history.
- Serial X‑ray reports.
NCD/LCD documentation required where applicable
Documentation and compliance with applicable NCDs/LCDs (for example Noridian LCD L33796) are required where applicable and may affect coverage and prior authorization decisions.
- Reference Noridian LCD L33796 and CMS Medicare Coverage Database when Medicare rules apply.
Investigational indications — denial risk
Requests for electrical bone growth stimulation for fresh fractures, delayed unions, avascular necrosis, stress fractures, or sacroiliac fusion are considered investigational and may be denied.
- Do not expect coverage for fresh fractures, delayed unions, avascular necrosis, stress fractures, or sacroiliac fusion under this policy.
Medicare/NCD‑LCD compliance may affect coverage and claims
Claims and prior authorization requests that are not in compliance with applicable NCDs/LCDs (for example Noridian LCD L33796) may be denied; Medicare coverage requirements apply where relevant.
- Ensure claims for Medicare members adhere to Noridian LCD L33796 and CMS guidance to avoid denial.
Background and Rationale
Electric bone growth stimulators deliver electrical current to promote bone healing and may be categorized by how the current is delivered: non-invasive devices use externally applied coils for treatment (typical outpatient application), semi-invasive/percutaneous devices use percutaneous electrodes placed through the skin, and invasive/implanted devices are surgically implanted and used as adjuncts to procedures such as spinal fusion or to support surgical treatment of non-union of major long bones. These devices aim to stimulate osteogenesis by providing an electrical stimulus to bone tissue to enhance the biological processes of bone repair.
Key Definitions
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