CurrentUnitedHealthcarePolicy CS037LA1.F

Electrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only)

Defines Louisiana Medicaid coverage policy for non-invasive electrical and ultrasonic osteogenic bone growth stimulators (spinal and non-spinal), excludes invasive stimulators and rental reimbursement, and lists applicable CPT/HCPCS codes and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only)

Policy CodePolicy CS037LA1.F

Change TypeTitle revision; added documentation requirements

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient medical record includes relevant history, physical exam, and pertinent diagnostic test/procedure results that are legible and available upon request to support medical necessity.

POLICY UPDATE CHANGES

Title changed from 'Electrical and Ultrasound Bone Growth Stimulators (for Louisiana Only)' to 'Electrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only)'.

Added Medical Records Documentation Used for Reviews language detailing documentation requirements to support medical necessity.

Non-invasiveCovered Indications

InvasiveExcluded

No rentalRental Exclusion

LouisianaScope

Coverage Summary

Overview: Louisiana Medicaid covers non-invasive electrical and ultrasonic osteogenic bone growth stimulators for augmenting bone repair related to healing fractures or fusions. Invasive (surgically implanted) stimulators are excluded and Medicaid will not approve payment for osteogenic bone growth stimulators as rentals because the item has not been FDA-approved for rental. Coverage and documentation requirements are determined by federal, state, or contractual requirements and medical records supporting medical necessity (history, physical exam, diagnostic tests) must be maintained and made available upon request.

Quick Policy Thresholds and Facts

Non-spinal electrical fracture failure timeframe6 months from initial date of treatment

Non-spinal electrical fusion failure timeframe9 months from initial date of treatment

Ultrasound evaluation interval90 days following treatment (two radiographs: baseline and 90 days)

Spinal failed fusion minimum timeframe9 months since fusion surgery

Effective date2026-02-01

Last review date2026-02-01

Policy numberCS037LA1.F

Medical Necessity Criteria

Osteogenic Bone Growth Stimulators - General

Medicaid coverage is limited to non-invasive electrical and ultrasonic bone growth stimulators; invasive devices and rental reimbursement are excluded.

Non-invasive required: Device must be a non-invasive electrical or ultrasonic osteogenic bone growth stimulator
Medicaid coverage is limited to reimbursement for electrical and ultrasonic non-invasive types of bone growth stimulators.
Invasive excluded: Invasive (surgically implanted) bone growth stimulators are excluded from reimbursement
Medicaid will not provide reimbursement for invasive types of bone growth stimulators.
Rental not reimbursed: Osteogenic bone growth stimulators are not approved by FDA for rental and will not be reimbursed as rental devices

Coding

CPT codes referenced (for bone healing procedures/stimulation)CPT

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)

HCPCS / DME codes (reporting bone growth stimulators)HCPCS

E0747	Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
E0748	Osteogenesis stimulator, electrical, noninvasive, spinal applications (Coding Clarification: Utilize HCPCS code E0748 when reporting bone growth stimulation for all anatomical levels of the spine)
E0749	Osteogenesis stimulator, electrical, surgically implanted
E0760	Osteogenesis stimulator, low intensity ultrasound, noninvasive

Provider Actions & Billing Notes

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports medical necessity for the requested services. Required documentation includes 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
Pertinent diagnostic tests/procedure results
Records must be legible, maintained, and available upon request

Documentation Required

Radiographic documentation for ultrasonic stimulators

For ultrasonic (low intensity ultrasound) bone growth stimulators, provide two sets of radiographs: one prior to treatment and a second set 90 days after treatment. Radiographs shall include multiple views and must be accompanied by a physician's written interpretation stating there has been no clinically significant evidence of fracture healing between the two sets. Relevant billing/coding references include HCPCS E0760 and CPT 20979.

Background

Background: Osteogenic bone growth stimulators are intended to augment bone repair for healing fractures or spinal/non-spinal fusions. Louisiana Medicaid limits reimbursement to non-invasive electrical and low-intensity ultrasonic stimulators and explicitly excludes invasive (surgically implanted) stimulators. The policy also states that these devices are not FDA-approved for rental and therefore rental reimbursement is not allowed. Medical records documentation (relevant history, physical exam, and pertinent diagnostic test/procedure results) may be required to assess coverage and must be legible, maintained, and made available upon request.

Definitions

Scope Summary & Policy Status

Revision History

2026-02-01title_changeLatest

Title changed from 'Electrical and Ultrasound Bone Growth Stimulators (for Louisiana Only)' to 'Electrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only)'.

2026-02-01material_changeLatest

Added 'Medical Records Documentation Used for Reviews' language specifying that benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess clinical criteria; and that patient records must fully support medical necessity (including relevant history, physical exam, and pertinent diagnostic tests), be legible, maintained, and made available upon request.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only)

Policy CodePolicy CS037LA1.F

Change TypeTitle revision; added documentation requirements

Effective DateFeb 1, 2026

Next Review Date

On This Page

This item has not been approved by FDA for rental. Therefore, Medicaid will not approve payment for an osteogenic bone growth stimulator as a rental device.

Non-Spinal Non-Invasive Electrical Stimulators (Coverage Criteria)

May be considered when any one of the following is met:

Failure of long bone fractures to heal6 months from initial date of treatment
A period of six months from the initial date of treatment must elapse before failure is considered to have occurred.
Failure of long bone fusions9 months from initial date of treatment
A period of nine months from the initial date of treatment must elapse before failure is considered to have occurred.
Congenital pseudoarthroses: Treatment of congenital pseudoarthrosesnone
There is no minimal time requirement after the diagnosis.

Non-Spinal Non-Invasive Ultrasonic Stimulators (Coverage Criteria)

All of the following must be met for consideration:

Non-union fracture failure interval: Failure of a non-union fracture to heal90 days following treatment
A period of 90 days following treatment has occurred.
Two sets of radiographs: Documentation consists of two sets of radiographs (one before treatment and one 90 days after treatment)baseline and 90-day radiographs
Radiographs shall include multiple views.
Physician interpretation: Written interpretation by a physician stating no clinically significant evidence of fracture healing between the two radiograph sets
Radiographs must be accompanied by a written interpretation by a physician stating there has been no clinically significant evidence of fracture healing between the two sets.

Spinal Non-Invasive Electrical Stimulators (Coverage Criteria)

May be considered when any one of the following Louisiana Department of Health–mandated conditions is met:

Failed fusion ≥9 months post-surgery: A minimum of nine months has elapsed since fusion surgery which resulted in a failed spinal fusion9 months since fusion surgery
Meaning more than nine months has elapsed since fusion surgery was performed at the same level which is being fused again; as long as nine months has passed since the failed fusion surgery, this repeated fusion attempt requires no minimum passage of time for application of the device.
History of previously failed fusion at same site: History of a previously failed spinal fusion at the same site following spinal fusion surgerymore than 9 months since the prior fusion
As long as nine months has passed since the failed fusion surgery, a repeated fusion attempt requires no minimum passage of time for application of the device.
Multi-level spinal fusion: Following a multi-level spinal fusion (three or more contiguous vertebrae, e.g., L3-L5 or L4-S1)none
There is no minimum requirement for application after surgery.

Affected codes: E0760, 20979
Two radiograph sets: baseline (pre-treatment) and 90 days post-treatment
Radiographs must include multiple views
Physician's written interpretation stating no clinically significant healing between sets

Billing Rule

Rental reimbursement restriction

Osteogenic bone growth stimulators are not approved by the FDA for rental. Therefore, Medicaid will not approve payment for these devices as rental items and providers should not bill rental reimbursement for osteogenic stimulators.

Device not FDA-approved for rental
Medicaid will not approve payment for rental of osteogenic bone growth stimulators

Billing Rule

Invasive stimulator exclusion

Invasive (surgically implanted) osteogenesis stimulators are excluded from Medicaid reimbursement. Do not bill Medicaid for surgically implanted bone growth stimulators.

Invasive (surgically implanted) stimulators are not reimbursed
Do not submit claims to Medicaid for implanted bone growth stimulators