CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Bone Growth Stimulator for the 5th Metatarsal

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This policy governs coverage and medical-necessity criteria for noninvasive ultrasonic and electrical bone growth stimulators used for 5th metatarsal fractures. It applies across specified commercial, Medicaid, Medicare Advantage, Family Health Center, and third-party administration products, subject to product-specific benefit documents and authorization requirements.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBone Growth Stimulator for the 5th Metatarsal

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateJune 1, 2026

Last ReviewMay 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization through Northwood before providing a covered bone growth stimulator service.

SourceLink

POLICY UPDATE CHANGES

The 2019 update removed fresh acute fracture treatment from the commercial clinical criteria.

The 2019 update added a limitation excluding use as part of acute treatment for fractures requiring open reduction and internal fixation.

The December 2025 update added Align, Align DSNP, and Great Plains Medicare Advantage plans effective January 1, 2026.

The May 2026 update revised the Medicare Policy Article link.

2Types of bone growth stimulators addressed

≤ 1 cm

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CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Bone Growth Stimulator for the 5th Metatarsal

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

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Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBone Growth Stimulator for the 5th Metatarsal

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateJune 1, 2026

Last ReviewMay 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization through Northwood before providing a covered bone growth stimulator service.

SourceLink

POLICY UPDATE CHANGES

The 2019 update removed fresh acute fracture treatment from the commercial clinical criteria.

The 2019 update added a limitation excluding use as part of acute treatment for fractures requiring open reduction and internal fixation.

The December 2025 update added Align, Align DSNP, and Great Plains Medicare Advantage plans effective January 1, 2026.

The May 2026 update revised the Medicare Policy Article link.

2Types of bone growth stimulators addressed

≤ 1 cm

Maximum fracture gap for nonunion treatment

≥ 3 monthsMinimum time before ultrasonic-stimulator nonunion treatment

90 daysMinimum imaging interval

ORIF acute treatmentExplicitly non-covered treatment setting

Medical Necessity Criteria

Ultrasonic Bone Growth Stimulator

Ultrasonic bone growth stimulator is considered medically necessary when ONE of the following criteria is met:

ONE of the following

Used as an adjunct to closed reduction and immobilization for treatment of a closed acute fracture of the 5th metatarsal. Fracture of the 5th metatarsal is difficult to heal because of poor vascular supply.
All of the following
- Nonunion of a fracture of the 5th metatarsal.
- Fracture gap is no more than 1 cm.≤ 1 cm
- Nonunion is not related or secondary to malignancy.
- At least three months have elapsed from the date of injury or initial treatment.≥ 3 months
- Fracture nonunion is documented by at least two sets of appropriate imaging studies separated by a minimum of 90 days, confirming that clinically significant fracture healing has not occurred.≥ 2 imaging sets; ≥ 90 days apart

Noninvasive Electrical Bone Growth Stimulator

A noninvasive electrical bone growth stimulator is considered medically necessary for a nonunion of a 5th metatarsal fracture when ALL of the following criteria are met:

ALL of the following

The bone is non-infected.
The two portions of the bone involved in the nonunion are separated by less than 1 cm.< 1 cm
Serial radiographs (x-rays) have confirmed that fracture healing has ceased for three or more months before starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of two sets, each including multiple views of the fracture site, separated by a minimum of 90 days.≥ 3 months; ≥ 2 radiograph sets ≥ 90 days apart

Ultrasonic osteogenic stimulators may not be used concurrently with other noninvasive osteogenic devices.

The service is non-covered when provided as part of the acute treatment of a fracture requiring open reduction and internal fixation (ORIF), including preoperative and immediately postoperative treatment.

Services not listed above with clinical criteria are considered experimental or investigational.

If the service does not meet the applicable clinical criteria above, it will be denied as not medically necessary.

Clinical Thresholds and Documentation Parameters

Ultrasonic nonunion fracture gap

Applicable conditionNonunion of a 5th metatarsal fracture

Maximum fracture gap≤ 1 cm

Coverage pathwayUltrasound bone growth stimulator treatment when all nonunion criteria are met

Ultrasonic nonunion elapsed time

Applicable conditionNonunion of a 5th metatarsal fracture

Minimum elapsed time≥ 3 months from the date of injury or initial treatment

Treatment pathwayUltrasound bone growth stimulator treatment

Authorization, Documentation, and Denial Risks

Prior Authorization

Northwood Prior Authorization Required

Prior authorization is required through Northwood for applicable services under the commercial policy, BadgerCare Plus/Medicaid SSI, Family Health Center (FHC), Medicare Advantage, and Third Party Administration (TPA) product lines. Contact Northwood before rendering services; TPA providers must also verify the member’s Summary Plan Description and apply commercial criteria when no specific SPD criteria exist.

Northwood portal: https://provider.northwoodinc.com
Northwood telephone: 866-532-1344
For BadgerCare Plus/Medicaid SSI, follow ForwardHealth requirements, including the interactive fee schedule for payable services, provider types, specialties, and places of service.
For TPA members, review the member’s SPD for coverage limitations and exclusions.

Prior Authorization

Medicare Advantage Authorization Path

For Align, Align DSNP, and Great Plains Medicare Advantage plans, prior authorization is required through the Health Plan, which follows Medicare guidelines. Other Medicare Advantage plans require prior authorization through Northwood.

Device Background

Noninvasive electrical bone growth stimulators are external devices that deliver electrical energy to a fracture or bone fusion site to induce osteogenesis and promote healing. Ultrasonic osteogenic stimulators are noninvasive devices that emit low-intensity, pulsed ultrasound through conductive coupling gel applied to the skin over the fracture site to stimulate healing.

Device Definitions

Noninvasive electrical bone growth stimulator (EBGS)

Device typeExternal, noninvasive electrical bone growth stimulator

Energy deliveredElectrical energy to a fracture or bone fusion site

Primary purposeInduce osteogenesis, stimulate bone growth, and promote healing

ApplicationsFresh, delayed, or nonunion bone fractures and surgical joint fusions

Ultrasonic osteogenic stimulator

Device typeNoninvasive ultrasonic osteogenic stimulator

Mechanism

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBone Growth Stimulator for the 5th Metatarsal

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateJune 1, 2026

Last ReviewMay 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization through Northwood before providing a covered bone growth stimulator service.

SourceLink

On This Page

Ultrasonic nonunion imaging interval

Required imagingAt least 2 sets of appropriate imaging studies

Minimum separation90 days between imaging sets

Imaging purposeConfirm that clinically significant fracture healing has not occurred

Electrical-stimulator nonunion fracture gap

Applicable conditionNonunion of a 5th metatarsal fracture

Maximum fracture gap< 1 cm

Device pathwayNoninvasive electrical bone growth stimulator treatment

Electrical-stimulator pre-treatment healing cessation

Applicable conditionNonunion of a 5th metatarsal fracture

Required healing cessation≥ 3 months before starting treatment

Confirmation methodSerial radiographs must confirm that fracture healing has ceased

Electrical-stimulator radiograph interval

Required radiographsAt least 2 sets of serial radiographs

Views per setEach set must include multiple views of the fracture site

Minimum separation90 days between radiograph sets

Applicable Medicare references: NCD 150.2, Osteogenesis Stimulators LCD L33796, Osteogenesis Stimulators—Policy Article LCA A52513, and Standard Documentation Requirements for Claims Submitted to DME MACs LCA A55426.

Documentation Required

Ultrasonic Nonunion Documentation

An ultrasonic bone growth stimulator for a 5th-metatarsal fracture nonunion is medically necessary only when all required documentation criteria are met.

Fracture gap is ≤ 1 cm.
Nonunion is not related or secondary to malignancy.
At least 3 months have elapsed since the date of injury or initial treatment.
Nonunion is documented by at least two sets of appropriate imaging studies, separated by a minimum of 90 days, confirming that clinically significant fracture healing has not occurred.

Documentation Required

Electrical Stimulator Documentation

A noninvasive electrical bone growth stimulator for a 5th-metatarsal fracture nonunion requires documentation that all clinical criteria are satisfied before treatment begins.

The bone is not infected.
The two portions of bone involved in the nonunion are separated by less than 1 cm.
Serial radiographs confirm that fracture healing ceased for 3 or more months before treatment.
Radiographs must include at least two sets, each with multiple views of the fracture site, separated by a minimum of 90 days.

Denial Risk

Criteria Not Met: Denial Risk

If the service does not meet the listed clinical criteria, it will be denied as not medically necessary. Services not listed with clinical criteria are considered experimental or investigational.

Confirm that the applicable fracture type, device, timing, imaging, and other clinical requirements are documented before submission.
Unlisted services may be denied as experimental/investigational.

Denial Risk

Concurrent Osteogenic Devices Not Covered

Ultrasonic osteogenic stimulators may not be used concurrently with other noninvasive osteogenic devices. Do not authorize or bill concurrent use of these devices.

Concurrent ultrasonic and other noninvasive osteogenic-device use is non-covered as experimental or investigational.

Denial Risk

Acute ORIF Treatment Not Covered

Bone growth stimulators are non-covered when used as part of the acute treatment of a fracture requiring open reduction and internal fixation (ORIF). This exclusion includes preoperative and immediately postoperative use.

Non-covered setting: acute fracture treatment requiring ORIF.
Includes preoperative and immediately postoperative use.
Classified as experimental or investigational.

Emits low-intensity, pulsed ultrasound

Application siteApplied to the skin at the fracture site

Coupling methodUltrasound waves are emitted via conductive coupling gel

PurposeStimulate fracture healing