Currentpartners_health_managementPolicy NC.CP.MP.194

Clinical Policy: Osteogenic Stimulation

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Medical necessity criteria for electrical (invasive and noninvasive) and ultrasonic osteogenic stimulators to enhance bone healing for covered members/enrollees of Partners Health Management (Centene-affiliated plans). Applies to clinical use indications, exclusions, and coding referenced in the policy.

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Osteogenic Stimulation

Policy CodePolicy NC.CP.MP.194

Change TypeNo material changes

Effective Date

Last ReviewAug 1, 2025

Next Review DateAug 1, 2025

Key ActionDocument serial imaging (minimum two sets separated by ≥90 days), absence of infection, gap <1 cm, and appropriate immobilization when requesting osteogenic stimulation for nonunion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Currentpartners_health_managementPolicy NC.CP.MP.194

Clinical Policy: Osteogenic Stimulation

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Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Osteogenic Stimulation

Policy CodePolicy NC.CP.MP.194

Change TypeNo material changes

Effective Date

Last ReviewAug 1, 2025

Next Review DateAug 1, 2025

Key ActionDocument serial imaging (minimum two sets separated by ≥90 days), absence of infection, gap <1 cm, and appropriate immobilization when requesting osteogenic stimulation for nonunion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=90dmin time since fracture/surgery

Medical Necessity Criteria for Osteogenic Stimulation

Noninvasive electrical osteogenesis stimulators — medically necessary

Covered when ANY of the following apply:

A: Nonunion of long bone fracture

A.1-A.4: All four must be met: 1) the bone is not infected; 2) the two portions of the bone involved in the non-union are separated by less than 1 cm; 3) the bone is stable at both ends by means of appropriate fracture care and immobilization; 4) serial imaging have confirmed that fracture healing has ceased for three or more months prior to starting treatment. Serial imaging must include a minimum of two sets of images, each including multiple views of the fracture site, separated by a minimum of 90 days.procedural
Imaging and timing requirements

B: Failed fusion (non-spine): Failed fusion of a joint other than the spine in which a minimum of six months has elapsed since the last surgery6 months

C: Congenital pseudoarthrosis: Congenital pseudoarthrosis

D: Adjunct to spinal fusion: As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion surgery or for those undergoing a multilevel spinal fusion (involving three or more vertebrae) or Grade III spondylolisthesis

E: Risk factors for delayed/nonunion: Risk of delayed or non-union of fractures due to conditions including but not limited to alcoholism, chemotherapy, diabetes, nutritional deficiency, obesity, osteoporosis, renal disease, severe anemia, tobacco or steroid use

Invasive electrical osteogenesis stimulators — medically necessary

Covered when ANY of the following apply:

A: Nonunion of long bone fracture: Nonunion of long bone fracture and ALL of the following must be met: 1) the bone is not infected; 2) the two portions of the bone involved in the non-union are separated by less than 1 cm; 3) the bone is stable at both ends by means of appropriate fracture care and immobilization; 4) serial imaging have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the invasive bone growth stimulator. Serial imaging must include a minimum of two sets of images, each including multiple views of the fracture site, separated by a minimum of 90 days.

B: Adjunct to spinal fusion: As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion surgery or for those undergoing a multilevel spinal fusion (involving three or more vertebrae) or Grade III spondylolisthesis

C: Risk factors: Risk of delayed or non-union of fractures due to conditions including but not limited to alcoholism, chemotherapy, diabetes, nutritional deficiency, obesity, osteoporosis, renal disease, severe anemia, tobacco or steroid use

Ultrasonic (LIPUS) osteogenesis stimulators — medically necessary

Covered when ANY of the following apply:

III.A Adjunct for fresh closed fractures at high risk: Used as an adjunct to conventional management (closed reduction and cast immobilization; fixation; custom bracing; or orthosis) for treatment of fresh, closed fractures when there is high risk for delayed fracture healing or nonunion and at least one listed risk factor exists. Criteria include specific anatomic fracture types and timing (examples: fractures associated with extensive soft tissue or vascular damage; fresh (≤7 days) closed or grade I open short oblique/short spiral tibial diaphyseal fractures treated with closed reduction and cast immobilization; fresh distal radius (Colles') fractures treated with closed reduction and cast immobilization; fresh Jones fracture of the 5th metatarsal; fresh scaphoid fractures).varies by fracture type

Policy lists specific fracture types and timing

III.B Nonunion (non-skull/vertebrae): Nonunion of bones other than the skull or vertebrae in skeletally mature patients, excluding tumor-related nonunions, when: 1) documented by a minimum of two sets of imaging obtained prior to starting treatment separated by a minimum of 90 days; and 2) the two portions of the bone involved in the non-union are separated by less than 1 cm.imaging and gap criteria

Key coverage criteria (summary)

Policy criteria were updated to require prior appropriate fracture care and immobilization and to add indications/adjunctive use for spinal fusion in high-risk patients.

Prior conservative care: Appropriate fracture care and immobilization (e.g., casting, custom bracing, orthosis) are required prior to consideration of osteogenic stimulation.

Updated language in criteria I.A.3 and II.A.3 per revision log

Device modalities: Electrical, electromagnetic, or low-intensity pulsed ultrasound modalities are included as osteogenic stimulation options.

Revision notes added electrical and clarified modalities

Spinal fusion adjunct indication: Adjunct to spinal fusion for patients at high risk of pseudoarthrosis due to previously failed fusion, multilevel fusion (three or more vertebrae), or Grade III spondylolisthesis.

New/clarified criterion II.B per revision log

Ultrasonic osteogenic stimulation (LIPUS) is not medically necessary when used in combination with other noninvasive osteogenic stimulators. The policy explicitly lists additional non-covered contexts including: avascular necrosis of the femoral head, stress fractures, fractures with a gap ≥ 1 cm between bone fragments, fresh fractures occurring in sites other than the enumerated locations (distal radius, tibial diaphysis, scaphoid, or Jones fracture of the 5th metatarsal), fresh tibial diaphyseal or tibial and fibular fractures treated with closed reduction and intramedullary nailing when no risk factors for poor healing are present, preoperative use when surgical fixation is required, and tibial stress fractures.

Osteogenic stimulation devices (electrical, electromagnetic, or ultrasonic) are not medically necessary for nonunion fractures of the skull or vertebrae, and for fractures that are tumor-related.

Several criteria were removed or reworded as part of the documented revisions. The revision log notes removal of specific prior criteria points (for example, an earlier III.6.c. was removed) and multiple language clarifications (such as changing 'radiographs' to 'imaging' and adding the term 'electrical' to certain sections). These changes and the dates of review/revision are recorded in the policy revision history.

Ultrasonic stimulation is not appropriate for several contexts specified by the policy, including treatment of avascular necrosis of the femoral head, general stress fractures, fractures with a separation of ≥ 1 cm, and many fresh fractures outside the enumerated high-risk sites. The policy further excludes preoperative use when surgical intervention or internal/external fixation will be performed and notes specific exclusions for fresh tibial fractures managed by closed reduction and intramedullary nailing when there are no additional risk factors for delayed healing.

Portions of earlier criteria were reformatted or removed during updates; the revision notes indicate criterion reorganization and omission of some prior numbered points. The available document excerpt does not reproduce every prior explicit 'not medically necessary' statement, but records that previous items were removed or reworded in the revision history.

Procedure and Supply Codes

Covered CPT Codes (referenced)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.

Supplies HCPCSHCPCS

A4559

Coupling gel or paste, for use with ultrasound device, per oz.

Coding implications / added codesHCPCS

E0760

Osteogenic stimulator device or supply (code added per revision log).

Imaging documentation for nonunion

Minimum imaging setsMinimum of two sets of imaging, each including multiple views of the fracture site, obtained prior to treatment

Minimum separation between imaging setsEach imaging set must be separated from the next by a minimum of 90 days

Purpose of serial imagingConfirm that fracture healing has ceased for three or more months prior to initiating osteogenic stimulation

Separation between bone fragments

Maximum allowed gapThe two portions of the bone involved in the nonunion must be separated by less than 1 centimeter (<1 cm)

Measurement context

Documentation, Authorization, and Billing Guidance

Prior Authorization

Use policy codes on authorization and claims

Submit claims and authorization requests using the specific CPT and HCPCS codes listed in the policy (e.g., CPT 20974, 20975, 20979; HCPCS E0747, E0748, E0749, E0760; supply A4559). Prior authorization and payment determinations rely on these codes being referenced on claims.

Include procedure code(s) that correspond to the modality (noninvasive electrical, invasive electrical, LIPUS)
Include HCPCS device/supply codes (E0747, E0748, E0749, E0760, A4559) as applicable

Prior Authorization

Coding update and Medicare review required

Be aware the policy update added HCPCS code E0760 (LIPUS) to the referenced codes. For Medicare members/enrollees, review applicable Medicare NCDs and LCDs before applying this policy’s criteria.

E0760 was added to the policy’s HCPCS list
Confirm consistency with Medicare NCDs/LCDs prior to authorization for Medicare members

Clinical Background on Fracture Healing and Osteogenic Stimulation

Fracture healing may be delayed or progress to nonunion in a minority of cases. Standard initial management for fractures includes stabilization measures such as casting, external or internal fixation, and appropriate immobilization; osteogenic stimulation is considered adjunctive therapy when conventional stabilization and immobilization have been applied and other coverage criteria are met.

Key Definitions

Definition — Nonunion

Basic definitionFailure of a fracture to heal with clinical findings and imaging evidence that healing has ceased for three or more months

Documentation requirementPolicy requires serial imaging demonstrating ceased healing with a minimum of two imaging sets (multiple views) separated by >=90 days

Additional policy requirementsNonunion coverage requires absence of infection, gap <1 cm, and stability at both bone ends with appropriate fracture care and immobilization

Definition — Multilevel spinal fusion

DefinitionMultilevel spinal fusion is defined as involving three or more vertebrae

Policy useUsed to identify patients who may qualify for adjunctive osteogenic stimulation when at high risk of pseudoarthrosis

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Osteogenic Stimulation

Policy CodePolicy NC.CP.MP.194

Change TypeNo material changes

Effective Date

Last ReviewAug 1, 2025

Next Review DateAug 1, 2025

Key ActionDocument serial imaging (minimum two sets separated by ≥90 days), absence of infection, gap <1 cm, and appropriate immobilization when requesting osteogenic stimulation for nonunion.

SourceLink

On This Page

III.C Risk factors: Risk of delayed or nonunion of any fresh, closed fractures due to conditions including but not limited to alcoholism, chemotherapy, diabetes, nutritional deficiency, obesity, osteoporosis, renal disease, severe anemia, tobacco or steroid use

Gap requirement applies to nonunion determinations for long bones and for ultrasonic nonunion criteria (non‑skull/vertebrae)

Denial triggerRequests may be denied if documented gap is greater than or equal to 1 cm

Time since fracture/surgical treatment for nonunion criteria

Nonunion time thresholdAt least 90 days must have passed since the date of fracture or the date of surgical treatment before nonunion criteria are met

Serial imaging durationHealing must have ceased for three or more months as documented by serial imaging prior to treatment

LIPUS referenceIn some ultrasonic (LIPUS) contexts, >9 months is referenced for certain nonunion considerations (policy notes include varied timing by indication)

Note

LIPUS is adjunctive and for daily at‑home use

When prescribing LIPUS the device is an adjunct to stabilization (for example, closed reduction and cast) and is intended for at‑home use 20 minutes once daily until healing occurs.

LIPUS is used in conjunction with stabilization of fresh fractures or as secondary therapy for nonunions
Patient-administered at home for 20 minutes once daily until healing

Step Therapy

Confirm prior conservative fracture management

Document that conservative fracture management has been provided prior to stimulation — e.g., appropriate fracture care and immobilization such as casting, custom bracing, or orthosis — per the policy’s requirement for prior conservative care.

Appropriate fracture care and immobilization (casting, custom bracing, orthosis) must be in place prior to consideration
This requirement is reflected across noninvasive, invasive, and ultrasonic criteria

Documentation Required

Provide serial imaging showing healing has ceased

For nonunion indications, submit serial imaging that demonstrates healing has ceased: a minimum of two sets of images (multiple views) obtained prior to treatment and separated by at least 90 days.

Minimum two imaging sets, each with multiple views
Imaging sets must be separated by a minimum of 90 days to document ceased healing

Documentation Required

Policy is a guide — follow coverage and legal requirements

Follow the Health Plan’s coverage documents and applicable state/federal requirements; this clinical policy is a guide to medical necessity but does not guarantee payment and does not override legal or contract requirements.

Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member’s coverage document
If discrepancies exist, state/federal requirements govern

Denial Risk

Denial triggers for nonunion and exclusions

Requests for osteogenic stimulation may be denied if exclusion or nonunion criteria are met — for example, documented infection at the fracture site, a gap of ≥1 cm between bone fragments, insufficient imaging (fewer than two imaging sets separated by ≥90 days), or inadequate elapsed time since fracture or surgery.

Active infection at the site precludes coverage
Gap between bone portions must be <1 cm; ≥1 cm is a denial trigger
Insufficient serial imaging or imaging not separated by ≥90 days risks denial
Failure to meet required time intervals since fracture/surgery (e.g., ≥90 days for nonunion) may result in denial

Note

Coverage decisions subject to plan terms and exclusions

Coverage and benefit administration remain subject to all terms, conditions, exclusions and limitations of the member’s coverage document; this policy does not establish coverage beyond the plan’s contractual provisions.

Administrative coverage decisions follow the member’s evidence of coverage/certificate of coverage/policy
Policy does not guarantee payment and may be superseded by plan-level or legal requirements

Associated criterionMultilevel fusion appears in adjunct-to-spinal-fusion indications (e.g., prior failed fusion or Grade III spondylolisthesis)

Definition — osteogenic stimulation

General definitionOsteogenic stimulation refers to therapies (electrical, electromagnetic, or low‑intensity pulsed ultrasound) intended to stimulate bone healing and promote union in fractures, delayed union, nonunion, and as adjunctive therapy for spinal fusion

Modalities includedElectrical (invasive and noninvasive) and ultrasonic (LIPUS) modalities are explicitly included in the policy

Intended usesUsed as adjuncts to stabilization or immobilization and for treatment of nonunion when policy criteria are met