ModifiedUnitedHealthcarePolicy CS037ID.B

Electrical and Ultrasound Bone Growth Stimulators (for Idaho Only)

Policy Summary

PayerUnitedHealthcare

PolicyElectrical and Ultrasound Bone Growth Stimulators (for Idaho Only)

Policy CodePolicy CS037ID.B

Change TypeRevised to defer clinical criteria to Idaho Medicaid handbook

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must follow the clinical coverage criteria in the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31: Osteogenesis Stimulators when requesting coverage or submitting claims for bone growth stimulators in Idaho.

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31 for medical necessity clinical coverage criteria.

Removed definitions for Delayed Union, Electrical Bone Growth Stimulator, Fracture Union, Nonunion Fracture, Ultrasonic Bone Growth Stimulator.

Updated References section to reflect the most current information.

1State-specific policy (Idaho only)

3Referenced device/procedure codes

State-specific UnitedHealthcare medical policy that governs coverage interpretation for electrical and ultrasound bone growth stimulators for members in Idaho, including Idaho Medicaid Plus; directs users to Idaho Medicaid Provider Handbook Chapter 5.31 for medical necessity criteria. This Medical Policy only applies to the state of Idaho, including Idaho Medicaid Plus plans. Coverage stance: mixed. Status: MODIFIED.

State-specific policyIdaho

Policy numberCS037ID.B

Effective dateAugust 1, 2025

Referenced handbookIdaho Medicaid Provider Handbook. Suppliers. 5.31. Osteogenesis Stimulators (accessed March 18, 2025)

Medical Necessity / Coverage Determination

Coverage Rationale / Medical Necessity Determination

Coverage and medical necessity criteria are determined by the Idaho Medicaid Provider Handbook; UnitedHealthcare policy defers to that handbook for clinical criteria.

For medical necessity clinical coverage criteria, refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31: Osteogenesis Stimulators

Clinical criteria are not contained in this policy; must use referenced handbook

This Medical Policy only applies the state of Idaho, including Idaho Medicaid Plus plans

Geographic/application limitation

Provider Requirements & Billing Notes

Documentation Required

Use Idaho Medicaid Provider Handbook for medical necessity

Providers must follow the clinical coverage criteria in the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31: Osteogenesis Stimulators when requesting coverage or submitting claims for bone growth stimulators in Idaho.

20974
20975
20979
E0747
E0748
E0749

Billing Rule

Spine reporting clarification

Utilize HCPCS code E0748 when reporting bone growth stimulation for all anatomical levels of the spine.

E0748

Referenced Procedure and Device Codes

Referenced CPT codes (procedure codes for bone growth 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)

Referenced HCPCS codes (osteogenesis stimulator devices)HCPCS

E0747	Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
E0748	Osteogenesis stimulator, electrical, noninvasive, spinal applications
E0749	Osteogenesis stimulator, electrical, surgically implanted

Background & Regulatory Information

UnitedHealthcare issues a state-specific medical policy for bone growth stimulators and this Idaho policy defers to the Idaho Medicaid Provider Handbook for clinical medical necessity criteria: For medical necessity clinical coverage criteria, refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31: Osteogenesis Stimulators. The FDA regards bone growth stimulators as Class III (significant-risk) devices (informational only).

Policy Revision Timeline

08/01/2025revisedLatest

Replaced coverage guidelines with instruction to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.31: Osteogenesis Stimulators for medical necessity clinical coverage criteria. (Material change)

08/01/2025removed

Removed many prior sections including Definitions (Delayed Union; Electrical Bone Growth Stimulator; Fracture Union; Nonunion Fracture; Ultrasonic Bone Growth Stimulator), Medical Records Documentation Used for Reviews, Description of Services, and Clinical Evidence; archived previous policy version CS037ID.A.

08/01/2025updated

Updated References section to reflect the most current information and added reference to Idaho Medicaid Provider Handbook (accessed March 18, 2025).