CurrentUnitedHealthcarePolicy CS037ID.C

Electrical and Ultrasonic Bone Growth Stimulators (Idaho)

Policy governing coverage interpretation for electrical and low-intensity ultrasound bone growth stimulators for members in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical and Ultrasonic Bone Growth Stimulators (Idaho)

Policy CodePolicy CS037ID.C

Change TypeTitle change and documentation clarification

Effective DateJun 1, 2026

Next Review Date

Key ActionEnsure patient medical records fully document the medical necessity (history, exam, and relevant test results) and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

Title changed and Medical Records Documentation Used for Reviews section added/expanded to clarify documentation expectations supporting medical necessity.

Idaho-onlystate-specific application

20974,20975,20979CPT codes referenced

E0747-E0749,E0760HCPCS codes referenced

FDA Class IIIdevice class

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Governing Clinical Criteria (external)

Coverage and medical necessity criteria

Reference to external criteria: For medical necessity clinical coverage criteria, refer to the Idaho Medicaid Provider Handbook, Provider Guidelines, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies: Osteogenesis Stimulators.

Policy delegates specific clinical criteria to Idaho Medicaid Provider Handbook.

The lists of procedure and billing codes included in this policy are provided for reference only. Listing a code in this policy does not imply the service described by the code is a covered or non-covered health service. Benefit coverage and medical necessity determinations are governed by applicable federal, state, or contractual requirements and laws and may vary by plan. Providers should not assume that inclusion of a code confers coverage or reimbursement rights; coverage is determined by the member’s specific benefit plan and applicable legal requirements.

Referenced Procedure and HCPCS Codes

Referenced CPT CodesCPT

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).

Referenced 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.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Governed by Contract/State Rules

Prior authorization requirements are governed by the member's federal, state, or contractual benefit plan. Check applicable federal, state or contractual benefit requirements before using this policy; those requirements supersede this Medical Policy if there is a conflict.

Prior authorization may be required per the member's contract or state law.

Note

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation may be requested to assess whether the member meets clinical criteria and should include, at a minimum, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Relevant medical history
Physical examination findings
Pertinent diagnostic test or procedure results
Treatment plans, progress notes, and response to prior therapies when applicable

Denial Risk

Documentation-Related Denials

Lack of adequate documentation to support medical necessity may result in denial of coverage for the requested service.

Device Definitions

Electrical Bone Growth Stimulator — definition and key properties

DefinitionDevice that delivers electrical stimulation to aid bone healing; may be noninvasive (external) or invasive (surgically implanted).

Common CPT/HCPCS codesCPT 20974 (noninvasive), CPT 20975 (invasive); HCPCS E0747 (nonspinal noninvasive), E0748 (spinal noninvasive), E0749 (surgically implanted).

Regulatory classFDA Class III (significant-risk) device — consult FDA product codes LOE and LOF for device-specific information.

Coding noteUse HCPCS E0748 when reporting bone growth stimulation for all anatomical levels of the spine.

Place in policyListed equipment type in DME section; medical necessity criteria are governed by the Idaho Medicaid Provider Handbook (referential).

Ultrasound Bone Growth Stimulator — definition and key properties

DefinitionLow-intensity ultrasound device that delivers noninvasive ultrasound stimulation to aid bone healing.

Common CPT/HCPCS codesCPT 20979 (low intensity ultrasound stimulation, noninvasive); HCPCS E0760 (low intensity ultrasound, noninvasive).

Regulatory classFDA Class III (significant-risk) device — consult FDA product code LPQ for ultrasound bone growth stimulators.

Policy placementIncluded as a DME equipment type; detailed medical necessity criteria are referenced to the Idaho Medicaid Provider Handbook.

Coverage noteInclusion of codes in the policy is for reference only and does not guarantee coverage; federal, state, or contractual requirements apply.

Referenced Medical Necessity Guidance

DME medical necessity (referenced)

See Idaho Medicaid Provider Handbook for detailed DME medical necessity criteria.

Referential criteria: Detailed medical necessity criteria (indications, duration, and conditions) are specified in the Idaho Medicaid Provider Handbook: Osteogenesis Stimulators.

This policy does not restate the handbook criteria.

Durable Medical Equipment Rental and Purchase Guidance

Equipment	Rental vs Purchase Rule	Notes / Governing Requirement
Bone growth stimulators (electrical and low-intensity ultrasound)	Dependent on applicable federal, state, or contractual benefit requirements	Coverage and whether equipment is rented or purchased are governed by the member's federal, state, or contractual benefit plan; in case of conflict those requirements govern over the standard benefit policy

Medical Records and Documentation Requirements

Documentation Required

Maintain and produce supporting documentation for coverage reviews

Maintain and produce supporting medical records for coverage reviews; records must fully support medical necessity and be made available upon request.

Ensure documentation includes history, exam, and pertinent diagnostic results
Keep records legible and retrievable for review

Background and Regulatory Context

Bone growth stimulators are devices intended to assist bone healing and include both electrical stimulators and low-intensity ultrasound stimulators. The U.S. Food and Drug Administration classifies bone growth stimulators as significant-risk devices (Class III), and product-specific regulatory information can be located by product code on FDA databases. Examples of covered device types in this policy include noninvasive and surgically implanted electrical osteogenesis stimulators and noninvasive low-intensity ultrasound osteogenesis stimulators.

Coverage Limitations and Non-Covered Statements

The inclusion of a CPT or HCPCS code in this policy does not guarantee coverage or payment. Listing of a code does not imply any right to reimbursement or guarantee claim payment. Providers should consult the member’s benefit plan, applicable federal or state rules, and other UnitedHealthcare policies and guidelines that may apply before assuming coverage.

Policy Changes and Revision History

2026-06-01Title and documentation updateLatest

Title changed from 'Electrical and Ultrasound Bone Growth Stimulators (for Idaho Only)' and expanded the Medical Records Documentation Used for Reviews section to clarify documentation requirements and supporting information; references updated and previous version CS037ID.B archived.