CurrentUnitedHealthcarePolicy CS037TN.S

Electrical Ultrasound Bone Growth Stimulators Tn Cs

Defines medical necessity criteria for invasive and non-invasive electrical bone growth stimulators and low-intensity pulsed ultrasound (ultrasonic) bone growth stimulators for Tennessee Medicaid and CoverKids, including covered indications, not medically necessary uses, documentation requirements, and applicable billing codes.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical Ultrasound Bone Growth Stimulators Tn Cs

Policy CodePolicy CS037TN.S

Change TypeCoverage criteria clarifications and documentation requirements

Effective DateFeb 1, 2026

Next Review Date

Key ActionPatient medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical exam, and diagnostic test results; documentation must be legible, maintained, and available upon request.

SourceLink

POLICY UPDATE CHANGES

Title updated; previously titled 'Electrical and Ultrasound Bone Growth Stimulators (for Tennessee Only)'.

Added language clarifying electrical stimulators are unproven and not medically necessary for indications not listed as proven (including stress fractures).

Revised coverage criteria for ultrasonic bone growth stimulators replacing wording 'date of most recent surgical operation' with 'date of most recent surgical procedure'.

Added medical records documentation language specifying records may be required and what documentation should include.

Updated Clinical Evidence and References sections to reflect current information.

2Proven Indications (EBGS and UBGS)

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Coverage Summary

This Tennessee Medicaid/CoverKids policy addresses bone growth stimulators (electrical and ultrasonic) and defines state-specific medical necessity criteria for coverage. Electrical stimulators are addressed as invasive (implantable) and non‑invasive devices intended to augment spinal fusion, and ultrasonic (low‑intensity pulsed ultrasound) stimulators are addressed for treatment of nonunion long‑bone fractures.

Coverage stance is mixed: the policy identifies proven and medically necessary uses for electrical stimulators as an adjunct to lumbar spinal fusion in patients meeting defined high‑risk criteria and for ultrasonic stimulators in nonunion long‑bone fractures that meet strict criteria, while declaring use for other indications (including stress fractures) unproven and not medically necessary.

State and scope: this policy applies to Tennessee Medicaid and CoverKids and includes documentation and billing guidance; medical records may be required to assess whether clinical criteria are met and to support medical necessity.

Summary of evidence gaps: the literature quality is heterogeneous with many studies at risk of bias; additional larger, high‑quality randomized controlled trials and standardized reporting (including consistent device parameters and clearer comparative effectiveness data) are needed to confirm benefits across indications and to resolve remaining uncertainty about non‑spine uses.

Policy thresholds and key meta facts

Fracture gap<= 1 cm

Persistent fracture line duration>= 3 months

Elapsed time since most recent surgical procedure (ultrasonic eligibility)< 6 months

Previously failed fusion elapsed time>= 6 months since last surgical procedure

State-specific scopeApplies to Tennessee Medicaid and CoverKids

Medical records requirementMedical record documentation may be required to support medical necessity (history, exam, diagnostic results)

Medical-Necessity Criteria

Coding

CPT codes (procedure-based references)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 codes (device/billing codes)HCPCS

E0747	Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
E0748	Osteogenesis stimulator, electrical, noninvasive, spinal applications. Coding clarification: Utilize HCPCS 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

Documentation Required

Medical records documentation required

Patient medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical exam, and diagnostic test results; documentation must be legible, maintained, and available upon request.

Relevant medical history (e.g., prior fusion attempts, comorbidities, smoking history)
Physical examination findings pertinent to the fracture or fusion site
Diagnostic test results (radiographs, CT scans showing persistent fracture line or fusion status)

Prior Authorization

Prior authorization expectation (implicit)

Policy applies to Medicaid and CoverKids Tennessee; medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and to support medical necessity. Although prior authorization is not explicitly stated, records may be requested to determine coverage.

Background & Evidence

Bone growth stimulators covered in this policy include: invasive electrical stimulators (implantable current generators with electrodes placed at the fusion site), non‑invasive electrical stimulators (external devices using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields), and ultrasonic (low‑intensity pulsed ultrasound) stimulators (external devices with a treatment head centered over the fracture site).

Intended uses: electrical stimulators are presented primarily as an adjunct to spinal fusion surgery for patients at increased risk of fusion failure; ultrasonic stimulators are intended for management of nonunion long‑bone fractures when specific radiographic and timing criteria are met.

Overall evidence quality: evidence across device types is heterogeneous. For electrical stimulators there is supportive evidence for augmentation of spinal fusion (including meta‑analytic findings of increased odds of fusion in postoperative electrical stimulation), but many studies are limited by bias, inconsistent reporting, and variable device parameters. For ultrasonic stimulators, systematic reviews and pooled analyses report favorable heal rates in nonunion but studies vary in quality and heterogeneity; overall, larger, well‑designed trials with standardized methods are needed.

Source	Summary
ECRI 2024 assessment	Noninvasive electrical stimulators can heal non-union tibia fractures; available studies are at high risk of bias and larger RCTs are needed
Leighton et al. 2017	Pooled heal rate ~82% for LIPUS in nonunions (any site, ≥3 months); heterogeneity across studies noted; stricter nonunion definition (≥8 months) pooled heal rate ~84%
Akhter et al. 2020	Moderate-level evidence that postoperative electrical stimulation increases odds of successful spinal fusion by ~2.5-fold compared with control

Invasive Electrical Bone Growth Stimulator: an implantable current generator surgically placed with an electrode implanted at the targeted fusion site; device usually functional for 6–9 months and may require removal.

Non‑Invasive Electrical Bone Growth Stimulator: an external device that generates a weak electrical current to the target sites using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields.

Ultrasonic Bone Growth Stimulator: a non‑invasive device that emits low‑intensity pulsed ultrasound to accelerate bone repair; consists of an operating unit with an external power supply and a treatment head module affixed over the fracture site.

Revision History

02/01/2026title_changeLatest

Title updated from 'Electrical and Ultrasound Bone Growth Stimulators (for Tennessee Only)' to 'Electrical Ultrasound Bone Growth Stimulators Tn Cs'.

02/01/2026clarifiedLatest

Added language clarifying Invasive and Non‑Invasive Electrical Bone Growth Stimulators are unproven and not medically necessary for all other indications not listed as proven (including stress fractures).