Bone Lengthening (Distraction Osteogenesis)
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This policy governs coverage of bone lengthening procedures for limb length discrepancies, limb deformities, nonunion or malunion, amputation stump lengthening, and bone defects. It applies to Regence members and providers, subject to the applicable member contract.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Bone Lengthening
Bone lengthening procedures may be considered medically necessary when <strong>both</strong> Criterion A and Criterion B are met.
ALL of the following
Criterion A — ONE of the following
- Correction of congenital or post-traumatic limb length discrepancies.
- Correction of angular deformities of the limb, including the arm, forearm, thigh, or leg.
Criterion B — ONE or more of the following
Both of the following must be met
- The individual has fracture nonunion or malunion of a long bone, with or without bone loss or infection.
The condition must be documented by both requirements below.
- At least 3 months have passed since the date of injury or treatment.
- Radiographic evidence on at least 2 serial imaging studies during the most recent 3-month period shows evidence of nonunion or malunion.
- Lengthening of an amputation stump is needed to ensure the proper fitting of a prosthesis.
- Bone lengthening is needed to equalize a leg length discrepancy greater than 6 cm.> 6 cm
- Correction of any congenital limb length discrepancy or post-traumatic angular-rotational deformities of the long bones.
- Bone lengthening is being used for bone defects, with or without deformities.
Not Medically Necessary
Bone lengthening is considered not medically necessary when the following exclusion conditions apply:
ALL of the following
- Criterion I is not met.
- The indication is a congenital or post-traumatic limb length discrepancy, or correction of an angular deformity of the limb, including the arm, forearm, thigh, or leg.
- The indication is other than short stature.
Cosmetic
Bone lengthening for the sole purpose of altering short stature is considered cosmetic.
There is enough research to show that bone lengthening improves health outcomes for individuals with congenital or post-traumatic limb length discrepancies and for correction of angular deformities of the limb, including the arm, forearm, thigh, or leg. Therefore, bone lengthening may be considered medically necessary when policy criteria are met.
For all other indications, excluding short stature, and for individuals who do not meet policy criteria, bone lengthening for congenital or post-traumatic limb length discrepancies and correction of angular deformities of the limb, including the arm, forearm, thigh, or leg, has not been shown to improve health outcomes and therefore is considered not medically necessary.
Bone lengthening for the sole purpose of altering short stature, in the absence of limb length discrepancy or deformity, is considered cosmetic.
Bone lengthening performed for the sole purpose of altering short stature is considered cosmetic.
Bone lengthening is considered cosmetic when performed in the absence of a limb length discrepancy or deformity and solely to alter short stature.
Coverage may be considered for congenital or post-traumatic limb length discrepancies and angular deformities of the limb, including the arm, forearm, thigh, or leg, when the medically necessary criteria are met.
Coverage is not medically necessary for other indications, excluding short stature, or for individuals who do not meet the policy criteria. Bone lengthening for the sole purpose of altering short stature is cosmetic.
Coding Information
| 0594T | Incision of upper arm bone and insertion of bone-lengthening device in marrow cavity. |
| 20690 | Placement of single direction external bone stabilizing device to arm or leg. |
| 20692 | Placement of multiple direction external bone stabilizing device to arm or leg. |
| 20693 | Revision of external bone stabilizing device under anesthesia. |
| 20696 | Placement of multiple direction external bone stabilizing device to arm or leg. |
| 20697 | Placement of multiple direction external bone stabilizing device to arm or leg using imaging. |
| 24420 | Reconstruction of upper arm bone. |
| 25391 | Lengthening of one of the forearm bones with patient-derived bone graft. |
| 25393 | Lengthening of both bones of forearm with patient-derived bone graft. |
| 27458 | Incision of thigh bone and insertion of bone-lengthening device in marrow cavity. |
| 27715 | Lengthening or shortening of lower leg bones. |
Documentation and Review Considerations
General Clinical Documentation Required
Submit complete clinical documentation to support review, including the patient’s history and physical or chart notes and the condition causing the limb length discrepancy or angular deformity. Document the amount of discrepancy and relevant congenital, traumatic, or angular-deformity details; missing support may affect the review and decision.
- History and physical or chart notes
- Description of the congenital condition, trauma, or angular deformity causing the discrepancy
- Amount of limb length discrepancy
Document Nonunion or Malunion
For fracture nonunion or malunion, submit documentation identifying the location and the date of injury or prior fracture treatment. Include serial radiographs showing no progressive signs of healing during the most recent three months.
- Nonunion or malunion location
- Date of injury or previous fracture treatment
- Serial radiographs documenting no progressive healing over the most recent three months
Document Amputation Stump Lengthening
For lengthening after amputation, document the limb length discrepancy and provide the post-procedure prosthesis-fitting plan.
- Description of the limb length discrepancy
- Plan for the post-procedure prosthesis
Criterion I Not Met
Bone lengthening is considered not medically necessary for congenital or posttraumatic limb length discrepancies, or for correction of angular deformities of the arm, forearm, thigh, or leg, when Criterion I is not met.
- Qualifying limb discrepancy or angular deformity criteria must be satisfied
- Failure to meet Criterion I creates denial risk
Solely Cosmetic Short-Stature Treatment
Bone lengthening performed solely to alter short stature is considered cosmetic. Coverage is subject to the applicable member contract, which takes precedence over the medical policy.
- Cosmetic procedures may be excluded by the member contract
- Inform the member before service when financial responsibility is likely
Insufficient Documentation or Contract Exclusion
Incomplete documentation or an applicable contract exclusion may prevent approval. Member contract language governs coverage, and contracts may exclude investigational or cosmetic services; providers should advise members when they may be financially responsible.
- Submit all documentation required to determine whether policy criteria are met
- Contract language takes precedence over the medical policy
- Providers may bill members for excluded investigational or cosmetic services
Indication or Criteria Not Met
For indications other than short stature, or when the policy criteria are not met, bone lengthening for congenital or posttraumatic limb length discrepancies or angular deformities has not been shown to improve health outcomes and is considered not medically necessary.
- Applies to all other indications excluding short stature
- Unmet policy criteria may result in denial
Cosmetic Short-Stature Lengthening
Bone lengthening performed solely to alter short stature, without a limb length discrepancy or deformity, is considered cosmetic and is at risk for denial under the applicable contract.
- Short stature alone does not establish a covered indication
- Absence of limb length discrepancy or deformity supports the cosmetic exclusion
Clinical Background
Bone lengthening, also called distraction osteogenesis, is a surgical technique used to lengthen or reconstruct bone. The bone is cut and a device gradually separates the bone ends, allowing new bone to form in the intervening space over several months. The technique may be used for limb-length discrepancies, deformity correction, fracture nonunion or malunion, amputation stump lengthening, and bone defects.
Key Definition
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