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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Bone Growth Stimulator Coverage | OpenP…
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    CurrentProvidence Health PlanPolicy 226

    Bone Growth Stimulators

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    This Medicare medical policy governs coverage and coding of bone growth stimulators, including noninvasive, invasive or surgically implanted, electrical, and low-intensity ultrasound devices and related services. Coverage decisions must follow applicable CMS guidance, the member's Evidence of Coverage, and individualized medical-necessity determinations.

    Policy Summary
    PayerProvidence Health Plan
    PolicyBone Growth Stimulators
    Policy CodePolicy 226
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionFor an unlisted code submitted for a potentially covered service addressed by this policy, prior authorization is recommended to help avoid a post-service denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    8CPT/HCPCS codes listed
    2CMS coverage references

    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.

    2Device delivery categories
    No changeAnnual revision status

    Coverage Criteria

    Medicare coverage criteria

    Coverage is governed by the most current applicable Medicare guidelines and CMS coverage references.

    Applicable CMS coverage guidance: Apply the most current applicable CMS coverage determination for the requested bone growth stimulator. Noninvasive osteogenic stimulators are addressed by NCD 150.2 and LCD L33796; LCD L33796 applies only to noninvasive stimulators.

    If Providence Health Plan policy conflicts with CMS guidance, CMS guidance governs.

    Invasive or surgically implanted stimulators

    Surgically implanted stimulators are evaluated under the applicable Medicare guidance, not the noninvasive DME MAC LCD.

    Implanted stimulator applicability: For HCPCS E0749 and other surgically implanted stimulator services, apply NCD 150.2 and other applicable Medicare rules. Do not apply DME MAC LCD L33796, because it applies only to noninvasive stimulators.

    LCD L33796 also does not apply to physician services to implant the device or administer electrical stimulation from an implanted device in the office.

    Services or items considered cosmetic, not medical in nature, or not medically reasonable and necessary under Title XVIII of the Social Security Act, §1862(a)(1)(A), may be excluded from coverage. Review the member’s Evidence of Coverage when coverage is uncertain.

    Items or services for which medical reasonableness and necessity are not established may be excluded or denied. Coverage may also be subject to the member’s benefit plan and applicable Medicare requirements.

    Medical Necessity

    CMS medical necessity

    DME medical necessity and coverage must be established under applicable CMS requirements.

    CMS medical-necessity requirements: The requested bone growth stimulator must satisfy the applicable CMS NCD or LCD requirements and all other Medicare statutory, benefit-category, coding, and coverage requirements.

    NCD 150.2 applies to osteogenic stimulators; LCD L33796 applies to noninvasive stimulators only.

    Coding

    Physician CPT CodesCPT
    20974Electrical stimulation to aid bone healing; noninvasive (nonoperative)
    20975Electrical stimulation to aid bone healing; invasive (operative)
    20979Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
    DME and Supply HCPCS CodesHCPCS
    A4559Coupling gel or paste, for use with ultrasound device, per oz.
    E0747Osteogenesis stimulator, electrical, non-invasive, other than spinal applications
    E0748Osteogenesis stimulator, electrical, non-invasive, spinal applications
    E0749Osteogenesis stimulator, electrical, surgically implanted
    E0760Osteogenesis stimulator, low intensity ultrasound, non-invasive

    Provider Actions

    Prior Authorization

    Prior Authorization Recommended for Potentially Covered Unlisted Codes

    For potentially covered services addressed in this policy, prior authorization is recommended before submitting an unlisted code to help avoid a post-service denial.

    • All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.
    • See the non-covered and prior authorization lists on the Company Medical Policy, Reimbursement Policy, Pharmacy Policy and Provider Information website for additional information.
    Denial Risk

    Benefit Exclusion or Lack of Medical Necessity

    A service or item may appear medically indicated but still be excluded by Medicare or the member’s benefit plan. Services or procedures that are cosmetic, not medical in nature, or not medically reasonable and necessary under Title XVIII of the Social Security Act, §1862(a)(1)(A), may be denied.

    Background

    Bone growth stimulation is used to promote bone healing in difficult-to-heal fractures or fusions by applying electrical or ultrasonic current to the fracture or fusion site. Electrical stimulation may be delivered noninvasively from outside the body or invasively through a surgically implanted device. Some stimulators qualify as durable medical equipment, while others do not.

    Definitions

    Bone growth stimulator
    DefinitionA bone growth or osteogenic stimulator used to promote bone healing by applying electrical or ultrasonic current to a fracture or fusion site.
    PurposePromotes bone healing in difficult-to-heal fractures or fusions.
    ApplicationBone growth stimulation may use electrical or ultrasonic current applied at the fracture or fusion site.
    Noninvasive stimulator
    DefinitionA stimulator applied from outside the body.
    Home useWhen the device is provided to the member for use at home, applicable DME codes are used.
    Applicable DME codes

    Not Covered

    The following are not covered: cosmetic or non-medical services or items; services or items that are not medically reasonable and necessary under Medicare or the member’s benefit plan; and services or items that are otherwise excluded by the applicable Medicare or member benefit.

    Policy Summary
    PayerProvidence Health Plan
    PolicyBone Growth Stimulators
    Policy CodePolicy 226
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionFor an unlisted code submitted for a potentially covered service addressed by this policy, prior authorization is recommended to help avoid a post-service denial.
    SourceLink
    On This Page
    Coverage CriteriaMedical NecessityCodingProvider ActionsBackgroundDefinitionsNot Covered
  1. Review the member Evidence of Coverage (EOC) when coverage is uncertain.
  2. A Medicare Advance Beneficiary Notice of Noncoverage (ABN) cannot be used for Medicare Advantage members.
  3. Submit a pre-service organization determination request when appropriate.
    4. Denial Risk

    Unlisted Code for Non-Covered Service

    An unlisted code submitted for a non-covered service addressed in this policy will be denied as not covered.

    • Unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.
    Billing Rule

    Coding, Benefit, and Claims Edits

    Code inclusion or omission does not imply or guarantee reimbursement or coverage. Coding and payment remain subject to provider contracts, member benefits, eligibility, utilization audit, and applicable claims-edit requirements.

    • The presence of an amount in the Medicare Physician Fee Schedule (MPFS) or MPFS Database (MPFSDB) does not mean CMS has determined that a service is covered or medically reasonable and necessary.
    • HCPCS/CPT codes may be subject to CMS National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) bundling edits and daily maximum edits, also known as medically unlikely edits (MUEs).
    • This policy does not take precedence over NCCI edits or MUEs; follow CMS coding guidelines and applicable code combinations.
    Documentation Required

    Incorrect CMS Reference for Implanted Stimulator

    Do not apply the DME MAC LCD for noninvasive osteogenic stimulators to an implanted stimulator. HCPCS E0749 reports a surgically implanted stimulator, and the DME MAC LCD does not apply to that item or to physician services to implant the device or administer its electrical stimulation in the office.

    • The noninvasive-stimulator references are NCD 150.2 and DME MAC LCD L33796.
    • Use applicable CMS guidance for HCPCS E0749 and related physician services.
    • If Company policy conflicts with CMS guidance, CMS guidance governs.
    Home-use noninvasive devices may be billed with E0747, E0748, or E0760, as applicable to the device.
    Invasive or surgically implanted stimulator
    DefinitionA stimulator applied from inside the body through surgical implantation.
    ApplicationElectrical stimulation is delivered invasively through a surgically implanted device.
    Applicable device codeHCPCS E0749 reports an electrical osteogenesis stimulator that is surgically implanted.