CurrentWPS Health InsurancePolicy PUM 250-0016-1812

Durable Medical Equipment (DME): Bone Growth Stimulators Medical Guideline

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This guideline governs coverage and medical necessity for invasive, non-invasive electrical, and external ultrasonic bone growth stimulators used for fractures, nonunion, joint fusion, spinal fusion, and related conditions. Coverage varies by benefit plan and is subject to plan terms, applicable law, and required documentation.

Policy Summary

PayerWPS Health Insurance

PolicyBone Growth Stimulators

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionReview the member's contract and endorsements for applicable exclusions, prior authorization requirements, and benefit requirements before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Distinct coverage indication categories

<1 cmMaximum fracture gap

3 monthsMinimum applicable interval

7Experimental or unproven use categories

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CurrentWPS Health InsurancePolicy PUM 250-0016-1812

Durable Medical Equipment (DME): Bone Growth Stimulators Medical Guideline

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Sign up for WPS Health Insurance Policy PUM 250-0016-1812 alerts

Get alerted when Policy PUM 250-0016-1812 changes without checking for updates manually.

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Policy Summary

PayerWPS Health Insurance

PolicyBone Growth Stimulators

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionReview the member's contract and endorsements for applicable exclusions, prior authorization requirements, and benefit requirements before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Distinct coverage indication categories

<1 cmMaximum fracture gap

3 monthsMinimum applicable interval

7Experimental or unproven use categories

3Core documentation categories required

Covered Indications and Exclusions

Lumbar spinal fusion

Covered when all applicable requirements are met:

Risk factor
- History of previous failed fusion.
- Grade II or greater spondylolisthesis.Grade II or greater
- Multilevel fusion, defined as fusion at more than one level.More than one level
- A comorbid condition that may impact bone healing, such as obesity, current smoking, diabetes, osteoporosis, renal disease, steroid use, or alcoholism.

Nonunion or failed joint fusion

Covered when all requirements are met, including either the nonoperative or postoperative imaging pathway:

The fracture gap is less than one centimeter.<1 cm
The fracture or joint arthrodesis occurred at least 3 months ago.≥3 months ago
Healing assessment pathway
- No surgical fixation was performed, and serial imaging obtained at least 3 months apart documents deficient or scarce callus.≥3 months apart
- Surgical fixation was performed, and imaging at least 3 months postoperatively demonstrates deficient or scarce callus.

Congenital pseudoarthrosis

Covered when the stated condition is present and there is no indication of infection:

Congenital pseudoarthrosis: A non-invasive electrical bone growth stimulator is used to treat congenital pseudoarthroses in the appendicular skeleton.

There is no indication of infection.

External ultrasonic stimulation

Covered when all requirements are met and there is no indication of infection:

Qualifying condition
- Delayed healing of a tibial osteotomy.
- Delayed union of a reduced and immobilized long-bone fracture.
- Failed joint arthrodesis.
Limited progress toward healing is demonstrated on serial radiographs or MR/CT obtained at least 3 months apart, with deficient or scarce callus.≥3 months apart
If surgery was performed, the most recent surgical procedure for the condition was within the last 6 months.

Scaphoid or fifth metatarsal fracture

Covered when the diagnosis is one of the specified acute or subacute fractures, requirements D.4 through D.6 are met, and there is no indication of infection:

Specified acute or subacute fracture

Fracture site
- Acute or subacute fracture of the scaphoid (navicular) bone of the wrist.
- Acute or subacute fracture of the fifth metatarsal of the foot.
Requirements D.4 through D.6
- The individual is skeletally mature.
- There is no indication of malignancy in the area.

Semi-invasive bone growth stimulators are considered experimental, investigational, and unproven to affect health outcomes and are not covered under this policy.

Use of an invasive or non-invasive electrical bone growth stimulator or ultrasonic bone growth stimulator for an acute or fresh fracture is considered experimental, investigational, and unproven, except for an acute fracture of the scaphoid of the wrist or the fifth metatarsal, when the applicable coverage criteria are met.

When a condition or diagnosis is listed in the indications of coverage but the applicable criteria are not met, the use is considered not medically necessary and is not covered under the applicable criteria. Use for a condition or diagnosis that is not listed in the indications of coverage is considered experimental, investigational, and unproven.

Key Coding and Clinical Thresholds

Fracture gap

ThresholdLess than one centimeter

Applies toFracture nonunion and external ultrasonic-stimulator criteria

Policy wordingThe fracture gap must be less than one centimeter.

Fracture or arthrodesis age

ThresholdAt least 3 months ago

Applies toThe fracture of a long bone or arthrodesis of a joint

Policy wordingThe fracture or joint arthrodesis must have occurred at least 3 months ago.

Provider Review and Submission Actions

Prior Authorization

Review Plan-Specific Requirements

Review the member’s applicable contract and endorsements before submission to identify exclusions, prior authorization requirements, and benefit-specific requirements.

Documentation Required

Standard Written Order Required

Submit a Standard Written Order (SWO) prescribed by a qualified healthcare provider concerning the member’s diagnosis.

Documentation Required

Medical Records and Medical Necessity

Provide medical records supporting medical necessity and, when applicable, continued need or use. Office notes must document the original injury, related surgical history, other applicable treatments, and current status.

Bone Growth Stimulator Overview

Bone growth stimulators, also called osteogenic stimulators, apply electrical or ultrasonic current to fractures or joint fusions to promote healing. Ultrasonic stimulation is applied externally, while electrical stimulation may be non-invasive or invasive.

Clinical Definitions

Acute or Fresh Fracture

DefinitionA fracture that occurred less than 14 days ago

TimeframeLess than 14 days from the fracture

TermAcute or Fresh Fracture

Delayed Union

DefinitionNo progressive radiographic signs of healing for at least 3 months

Signs assessedCallus, periosteal reaction, or a less distinct fracture line

Assessment methodRadiographic evaluation

Medical Necessity Determination

Covered bone growth stimulator indications

Equipment is medically necessary only when it is used for a covered clinical indication and all applicable criteria are met:

Covered equipment indication

Qualifying lumbar spinal fusion with an invasive or non-invasive electrical bone growth stimulator and at least one listed risk factor, with no indication of infection.
Non-pathological fracture nonunion of a long bone of the appendicular skeleton or failed joint fusion secondary to failed joint arthrodesis, meeting the applicable gap, timing, imaging, stability, malignancy, and infection requirements.
Congenital pseudoarthrosis in the appendicular skeleton treated with a non-invasive electrical bone growth stimulator, with no indication of infection.
Delayed healing of tibial osteotomy, delayed union of a reduced and immobilized long-bone fracture, or failed joint arthrodesis treated with an external ultrasonic or low intensity pulsed ultrasound bone growth stimulator, meeting the applicable imaging, surgery timing, skeletal maturity, malignancy, fracture-gap, and infection requirements.

Required Documentation

Documentation Required

Include a qualifying written order

Submit a Standard Written Order prescribed by a qualified healthcare provider. The order must concern the member’s diagnosis.

Documentation Required

Include complete medical records and office notes

Submit medical record information supporting medical necessity and continued need or use when applicable. Office notes must include the original injury, related surgical history, other applicable treatments, and current status.

Documentation Required

Provide supporting imaging reports

Provide X-ray or other applicable imaging reports supporting the diagnosis and coverage criteria.

Excluded and Noncovered Uses

The following uses are not covered or are considered experimental, investigational, and unproven: semi-invasive bone growth stimulators; use for conditions or diagnoses not listed in the indications of coverage; use for a listed condition when the required criteria are not met; stress or insufficiency fractures; pathological fractures or underlying bony malignancy; cervical spinal surgery; spondylolysis or pars interarticulares fractures; vertebral compression or odontoid fractures; avascular necrosis or bone infarcts; synovial pseudoarthrosis; fracture gaps greater than 1 cm; treatment less than 3 months after the fracture or most recent operative treatment, except for scaphoid wrist fracture; sesamoid fractures; acute osteotomy; acute joint fusion or arthrodesis other than lumbar spinal fusion; and treatment of the calvarium or tarsal bones, except for arthrodesis nonunion. Acute or fresh fractures are also excluded except for acute scaphoid wrist or fifth metatarsal fractures meeting the applicable criteria.

Policy Summary

PayerWPS Health Insurance

PolicyBone Growth Stimulators

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionReview the member's contract and endorsements for applicable exclusions, prior authorization requirements, and benefit requirements before requesting coverage.

SourceLink

On This Page

≥3 months postoperatively

The fracture is adequately immobilized and stable, with no evidence of hardware loosening or failure when hardware is present.

Within the last 6 months

The individual is skeletally mature.

There is no indication of malignancy in the area.

The fracture gap is less than one centimeter.<1 cm

Serial imaging interval

IntervalAt least 3 months apart

Applies toSerial radiographs or MR/CT used to demonstrate limited progress toward healing

Required findingDeficient or scarce callus

Most recent surgery for ultrasonic-stimulator indication

Time requirementWithin the last 6 months

Applies toThe most recent surgical procedure for the condition

When applicableIf surgery had been performed for the ultrasonic-stimulator indication

Documentation Required

Imaging Reports Required

Submit X-ray or other applicable imaging reports supporting the requested bone growth stimulator and the serial evidence required by the applicable coverage criteria.

Billing Rule

Correct Coding Required

Use the correct coding for the item or service and ensure that the submitted coding meets all applicable coding guidelines.

Denial Risk

Unlisted or Unmet Indication Criteria

If the device is used for a condition or diagnosis not listed in the Indications of Coverage, the use is considered experimental, investigational, and unproven to affect health outcomes. If a listed indication does not meet the applicable criteria, it is considered not medically necessary.

Denial Risk

Semi-Invasive Devices

Semi-invasive bone growth stimulators are considered experimental, investigational, and unproven to affect health outcomes.

Denial Risk

Excluded Clinical Uses

Invasive or non-invasive electrical bone growth stimulators and ultrasonic bone growth stimulators are considered experimental, investigational, and unproven when used to treat or in the presence of any of the following conditions or circumstances:

Acute or fresh fracture, except acute fractures of the scaphoid of the wrist or fifth metatarsal.
Stress or insufficiency fracture.
Pathological fracture or underlying bony malignancy.
Cervical spinal surgery.
Spondylolysis or pars interarticulares fractures.
Vertebral compression fracture or odontoid fracture.
Avascular necrosis or treatment of bone infarcts.
Synovial pseudoarthrosis.
Fracture gap greater than one centimeter.
Less than three months since the fracture or most recent operative treatment, except for a scaphoid wrist fracture.
Sesamoid fracture.
Acute osteotomy.
Acute joint fusion or arthrodesis, other than lumbar spinal fusion.
Treatment of the calvarium or tarsal bones, except in cases of arthrodesis nonunion.

Long Bones

Included long bonesClavicle, femur, tibia, fibula, humerus, radius, and ulna

Hand and foot bonesMetacarpals and metatarsals of the hands and feet

Finger and toe bonesPhalanges of the fingers and toes

Acute or subacute fracture of the scaphoid (navicular) bone of the wrist or fifth metatarsal of the foot, meeting the skeletal maturity, malignancy, fracture-gap, and infection requirements.

Billing Rule

Meet coding requirements

Submit coding for the item or service that meets all applicable coding guidelines.