Electrical Bone Growth Stimulation of the Appendicular Skeleton
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This policy governs coverage of noninvasive electrical bone growth stimulation for the appendicular skeleton (shoulder girdle, upper extremities, pelvis, lower extremities) and states when the service may be considered medically necessary or investigational; it is directed to providers submitting claims or prior authorization requests to Premera Bluecross.
No material clinical or coverage changes in this revision.
Coverage Criteria for Electrical Bone Growth Stimulation
Medical Necessity — Noninvasive Electrical Bone Growth Stimulation
Covered when ALL of the following are met:
Nonunion diagnosis criteria
- Fracture nonunion specific requirements: At least 3 months have passed since the date of fracture; serial radiographs have confirmed no progressive signs of healing; fracture gap is 1 cm or less; the individual can be adequately immobilized; the individual is of an age likely to comply with nonweight bearing during treatment when required.
All conditions must be met
Implantable and semi-invasive stimulators are considered investigational and are not covered.
Investigational / Not Covered Indications
Implantable and semi-invasive devices are considered investigational as well.
Coverage by indication
Coverage conclusions by indication based on available evidence and FDA labeling:
CMS defines nonunion as healing ceased for >=3 months with serial radiographs separated by >=90 days; serial radiographs requirement cited.
Considered investigational/insufficient.
Not supported for routine use in fresh fractures.
Insufficient evidence to support routine use.
Insufficient evidence.
No FDA-cleared semi-invasive devices identified.
Invasive (implantable) and semi-invasive electrical bone growth stimulators are considered investigational and are not approved for coverage under this policy. The policy specifically distinguishes those device types from noninvasive stimulators and states that additional study is needed to determine safety and effectiveness.
No semi-invasive electrical bone growth stimulator devices with FDA approval or clearance were identified. Available evidence for implantable and semi-invasive stimulators is limited (primarily small case series), and the policy concludes that the evidence is insufficient to determine improvement in net health outcome; therefore these devices are not supported for coverage.
This medical policy does not apply to Medicare Advantage plans. Member contract benefits vary; providers and members should consult the member benefit booklet or contact customer service to determine coverage under specific plans.
Use of electrical bone growth stimulation for the following indications is considered investigational / not medically necessary: delayed union, fresh fractures, stress fractures, immediate postsurgical treatment after appendicular skeletal surgery, and arthrodesis. The policy also notes that implantable and semi-invasive devices are investigational across these indications.
Use of noninvasive electrical bone growth stimulation for fresh fractures, stress fractures, delayed union, and routine postoperative use is not supported by consistent evidence of net health benefit. Randomized trials and meta-analyses did not show clear, clinically meaningful improvements for these indications, and the policy therefore considers such uses investigational/insufficient.
Coding and Key Parameters
| 20974 | Electrical stimulation to aid bone healing; noninvasive (non-operative) |
| 20975 | Electrical stimulation to aid bone healing; invasive (operative) |
| E0747 | Osteogenesis stimulator, electrical, noninvasive, other than spinal applications |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted |
| FDA product code LOF | Electrical bone growth stimulators |
Provider Actions, Documentation, and Prior Authorization
Prior authorization / benefit adjudication
Noninvasive electrical bone growth stimulation may be adjudicated under durable medical equipment (DME) benefits; use applicable CPT/HCPCS codes (e.g., CPT 20974, HCPCS E0747) when submitting for benefit determination and prior authorization per the member's plan.
- Devices may be billed under DME benefits.
- Include CPT/HCPCS codes on requests to aid adjudication.
Device-specific prior authorization
Indicate the specific FDA‑cleared device model and the clinical indication (for example, established fracture nonunion or congenital pseudarthrosis) on prior authorization requests; prior authorization is likely required per benefit rules.
- List device name/model from FDA‑cleared Table 1 when available.
- State the indication consistent with FDA labeling.
Confirm prior authorization and benefits
Confirm prior authorization requirements and member benefits before providing or billing for a stimulator; this policy is a guide for Company staff but member contracts differ and prior authorization may be required per the member benefit booklet or customer service.
- Verify prior authorization rules with the member benefit booklet or customer service.
- Do not assume coverage based solely on this policy.
Step therapy not specified
This policy does not specify a step‑therapy program for electrical bone growth stimulation.
Conservative care before advanced therapy
Attempt conservative measures and mitigation of risk factors for delayed union/nonunion before progressing to surgical repair or stimulation therapies; document these efforts in the medical record.
- Address modifiable risk factors for delayed healing prior to advanced interventions.
- Document conservative care and rationale for advancing therapy.
Provider-action placeholder
(Reserved for future provider-action content.)
Required documentation for medical necessity
Medical records must document relevant history and physical exam supporting the diagnosis and the specific nonunion criteria: date of fracture (≥3 months), serial radiographs confirming lack of progressive healing, fracture gap measurement (≤1 cm), ability to immobilize, and age likely to comply with nonweight bearing when required.
- Include date of initial fracture and clinical history supporting nonunion.
- Record fracture gap (≤1 cm) and ability to immobilize or comply with restrictions.
Required clinical documentation — serial radiographs
Include serial radiographs (minimum two sets, multiple views) separated by at least 90 days showing cessation of healing; record device type (noninvasive vs implantable) and intended daily use regimen when relevant.
- Provide at least two radiograph sets, multiple views, ≥90 days apart, showing no progression.
- Document device type and prescribed daily wear/use schedule.
Verify member benefits
Verify the member's benefit booklet or contact customer service to determine whether electrical bone growth stimulation is covered under the member's plan and whether prior authorization or DME benefit adjudication applies.
- Consult member benefit booklet for plan‑specific limits and prior authorization requirements.
- Contact customer service when benefit language is unclear.
Failure to meet nonunion criteria — denial risk
Requests will be denied if documentation does not demonstrate the fracture nonunion criteria: at least 3 months since the date of fracture, serial radiographs showing no progressive healing, fracture gap ≤ 1 cm, ability to immobilize, and age/compliance for nonweight bearing when required.
- Failure to document any required nonunion element may result in denial.
- Ensure radiographs and clinical notes explicitly meet each criterion.
Implantable and semi‑invasive devices — investigational
Requests for implantable or semi‑invasive electrical bone growth stimulators are considered investigational and are subject to denial; do not submit implantable/semi‑invasive stimulator requests as routinely covered therapy.
- Implantable and semi‑invasive stimulators lack evidence and are investigational.
- Coverage decisions will likely deny implantable/semi‑invasive device requests.
Document established nonunion per CMS or risk denial
If CMS nonunion documentation standards are not met, requests are at high risk for denial — CMS requires that healing has ceased for 3 or more months with serial radiographs separated by at least 90 days.
- Provide serial radiographs separated by ≥90 days demonstrating cessation of healing to align with CMS standards.
- Cite radiograph dates and findings clearly in the request.
Benefit limitations may trigger denial
Coverage is subject to the member benefit plan limits and conditions; consult the member benefit booklet or customer service to determine applicable benefit limitations that may cause denial.
- Member contracts differ — plan limits may restrict coverage.
- Confirm any quantity, duration, or DME exclusions before treatment.
Background and Scope
Electrical bone growth stimulators transmit electrical pulses or current toward bone using three main approaches: noninvasive systems that deliver current through external patches or coils placed near the fracture site; semi-invasive systems that use percutaneous needle-like electrodes with an external power supply; and invasive (implantable) systems that surgically place electrodes and a generator within the body.
Definitions
Revision History and References
Last revised; policy document updated with most recent review and effective date set to 2026-07-01.
Coding update added CPT code 20975 and HCPCS code E0749.
Policy reinstated after planned deletion; pseudarthrosis was added to the policy and coding removed (CPT 20975 and HCPCS E0749 removed in earlier coding update).
New policy created, replacing policy 7.01.529 with literature review through November 4, 2014.
Annual review with literature update through March 2016; policy statements rewritten for usability and definition of congenital pseudoarthrosis added.
Annual review and format migration with literature update through February 23, 2017.
Annual review with literature update through February 2018; policy statements unchanged.
Annual review with literature update through 2019; policy updated accordingly.
Annual review with literature update through January 11, 2021; coding changes previously applied and policy statements unchanged.
Annual review with literature update through January 17, 2022; policy statements unchanged.
Annual review with literature update through January 13, 2023; minor editorial refinements and terminology standardized from 'patient' to 'individual'.
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