Aetna Bone Growth Stimulators coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Ultrasonic (low-intensity ultrasound) osteogenesis stimulator covered as DME to accelerate healing of fresh fractures, fusions, or delayed unions at high-risk sites (poor vascular supply) — ANY ONE of: (a) fresh closed or Grade I open, short oblique or short spiral fractures/fusions/delayed unions of the shaft (diaphysis) of the tibia treated with closed reduction and cast immobilization; OR (b) fresh fractures/fusions/delayed unions of the scaphoid (carpal navicular); OR (c) fresh fractures/fusions/delayed unions of the 5th metatarsal (Jones fracture); OR (d) fresh fractures/fusions/delayed unions of the distal radius (Colles fracture) treated with closed reduction and cast immobilization
• Ultrasonic osteogenesis stimulator covered for non-unions, failed arthrodesis, and congenital pseudarthrosis of the appendicular skeleton when ALL of the following are met: no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care; AND bone is non-infected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record
• Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for delayed unions of fractures or failed arthrodesis at high-risk sites — high-risk sites being open or segmental tibial fractures, carpal navicular fractures, 5th metatarsal fractures, distal radius, and sesamoid bones (fibular sesamoid in the foot) — AND when ALL of the following are met: bone is noninfected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record
• Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for non-unions, failed fusions, and congenital pseudarthrosis where there is no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care — AND when ALL of the following are met: bone is noninfected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record
• Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for spinal fusion when ANY ONE of: a multiple-level fusion entailing 3 or more vertebrae (e.g., L3 to L5, L4 to S1, etc.); OR Grade II or worse spondylolisthesis; OR one or more failed fusions

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 20974·PA verdict·Rate
• 20975·PA verdict·Rate
• 20979·PA verdict·Rate
• E0747·PA verdict·Rate
• E0748·PA verdict·Rate
• E0749·PA verdict·Rate
• E0760·PA verdict·Rate

Documentation required

• For ultrasonic osteogenesis stimulator in non-union cases (per referenced Medicare guidelines): nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days, with each radiograph set including multiple views of the fracture site accompanied by a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs
• For electrical stimulation in non-spinal nonunion of a long bone fracture (per referenced Medicare guidelines): documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, with written interpretation by a physician stating no clinically significant evidence of fracture healing between the two radiograph sets
• For non-unions/failed fusions/congenital pseudarthrosis indications: medical record must clearly document that the two portions of the involved bone are separated by less than 1 cm

Frequently asked questions

When does Aetna cover Bone Growth Stimulators (CPT 20974), and what gets it denied?

Aetna covers bone growth stimulators only in narrow situations: ultrasonic (low-intensity ultrasound) and electrical (invasive direct-current or non-invasive inductive/capacitive coupling) stimulators are medically necessary for fresh fractures/delayed unions at specified high-risk poorly-vascularized sites (tibial shaft, scaphoid, 5th metatarsal Jones fracture, distal radius, and for electrical also sesamoid/segmental tibia), and for non-unions/failed fusions/congenital pseudarthrosis when the bone is non-infected, stably fixed, the fragment gap is under 1 cm, and X-rays show no healing progression for 3 or more months. Electrical stimulators are also covered as an adjunct to spinal fusion only when there is a 3-or-more-vertebrae fusion, Grade II or worse spondylolisthesis, or one or more prior failed fusions. Semi-invasive stimulators are experimental for all uses, and many other indications (axial-skeleton fractures, avascular necrosis, stress fractures, Charcot, pre-operative use, etc.) are excluded as experimental/investigational. Coverage criteria include: Ultrasonic (low-intensity ultrasound) osteogenesis stimulator covered as DME to accelerate healing of fresh fractures, fusions, or delayed unions at high-risk sites (poor vascular supply) — ANY ONE of: (a) fresh closed or Grade I open, short oblique or short spiral fractures/fusions/delayed unions of the shaft (diaphysis) of the tibia treated with closed reduction and cast immobilization; OR (b) fresh fractures/fusions/delayed unions of the scaphoid (carpal navicular); OR (c) fresh fractures/fusions/delayed unions of the 5th metatarsal (Jones fracture); OR (d) fresh fractures/fusions/delayed unions of the distal radius (Colles fracture) treated with closed reduction and cast immobilization; Ultrasonic osteogenesis stimulator covered for non-unions, failed arthrodesis, and congenital pseudarthrosis of the appendicular skeleton when ALL of the following are met: no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care; AND bone is non-infected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record; Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for delayed unions of fractures or failed arthrodesis at high-risk sites — high-risk sites being open or segmental tibial fractures, carpal navicular fractures, 5th metatarsal fractures, distal radius, and sesamoid bones (fibular sesamoid in the foot) — AND when ALL of the following are met: bone is noninfected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record; Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for non-unions, failed fusions, and congenital pseudarthrosis where there is no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care — AND when ALL of the following are met: bone is noninfected; AND bone is stable on both ends by means of cast or fixation; AND the two portions of the involved bone are separated by less than 1 cm as clearly documented in the medical record; Electrical bone-growth stimulators (direct current invasive/implantable, OR non-invasive inductive coupling, OR non-invasive capacitive coupling) covered for spinal fusion when ANY ONE of: a multiple-level fusion entailing 3 or more vertebrae (e.g., L3 to L5, L4 to S1, etc.); OR Grade II or worse spondylolisthesis; OR one or more failed fusions. Applies to 7 codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For ultrasonic osteogenesis stimulator in non-union cases (per referenced Medicare guidelines): nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days, with each radiograph set including multiple views of the fracture site accompanied by a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs; For electrical stimulation in non-spinal nonunion of a long bone fracture (per referenced Medicare guidelines): documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, with written interpretation by a physician stating no clinically significant evidence of fracture healing between the two radiograph sets; For non-unions/failed fusions/congenital pseudarthrosis indications: medical record must clearly document that the two portions of the involved bone are separated by less than 1 cm. Policy exclusions and limitations: Ultrasonic osteogenesis stimulator is experimental/investigational for fractures (including lumbar compression fracture, stress fracture, and avulsion fracture of the hip), failed fusions, or non-unions of the axial skeleton (skull and vertebrae); Ultrasonic osteogenesis stimulator is experimental/investigational for avascular necrosis of the femoral head; Ultrasonic osteogenesis stimulator is experimental/investigational for calcaneal apophysitis (Sever disease); Ultrasonic osteogenesis stimulator is experimental/investigational for Charcot arthropathy; Ultrasonic osteogenesis stimulator is experimental/investigational for fractures with post-reduction displacement of more than 50% (opposing broken bone ends out of alignment by more than one half of the width of the bone); Ultrasonic osteogenesis stimulator is experimental/investigational for iliac apophysitis; Ultrasonic osteogenesis stimulator is experimental/investigational for pathological fractures due to malignancy (unless the neoplasm is in remission); Ultrasonic osteogenesis stimulator is experimental/investigational for pre-operative use for fractures that require surgical intervention or internal or external fixation; Ultrasonic osteogenesis stimulator is experimental/investigational for stress fractures; Ultrasonic osteogenesis stimulator is experimental/investigational for talar dome lesion following osteochondral autograft transfer system (OATS); Ultrasonic osteogenesis stimulator is experimental/investigational for all other indications not listed as covered (list not all-inclusive); the medical literature does not support its use; Electrical bone-growth stimulator is experimental/investigational for avascular necrosis of the hip; Electrical bone-growth stimulator is experimental/investigational for Charcot arthropathy; Electrical bone-growth stimulator is experimental/investigational for Charcot foot; Electrical bone-growth stimulator is experimental/investigational for comminuted toe fracture; Electrical bone-growth stimulator is experimental/investigational for fractures of the scapula or pelvis; Electrical bone-growth stimulator is experimental/investigational for loosened hip prosthesis; Electrical bone-growth stimulator is experimental/investigational for loosened knee prosthesis; Electrical bone-growth stimulator is experimental/investigational for lunate fractures; Electrical bone-growth stimulator is experimental/investigational for odontoid fractures; Electrical bone-growth stimulator is experimental/investigational for pre-operative use for fractures that require surgical intervention or internal or external fixation; Electrical bone-growth stimulator is experimental/investigational for sacroiliac fusion; Electrical bone-growth stimulator is experimental/investigational for spondylolysis (also known as pars inter-articularis fracture); Electrical bone-growth stimulator is experimental/investigational for stress fractures; Electrical bone-growth stimulator is experimental/investigational for all other indications not listed as covered (list not all-inclusive) due to lack of adequate evidence of effectiveness; Semi-invasive bone growth stimulators are experimental/investigational for ALL indications, including treatment of orthopedic and neurosurgical conditions (e.g., delayed unions, failed spinal fusions, fracture non-unions, fresh fractures, and pseudoarthroses), because of a lack of adequate evidence of their effectiveness. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Bone Growth Stimulators?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For ultrasonic osteogenesis stimulator in non-union cases (per referenced Medicare guidelines): nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days, with each radiograph set including multiple views of the fracture site accompanied by a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs; For electrical stimulation in non-spinal nonunion of a long bone fracture (per referenced Medicare guidelines): documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, with written interpretation by a physician stating no clinically significant evidence of fracture healing between the two radiograph sets; For non-unions/failed fusions/congenital pseudarthrosis indications: medical record must clearly document that the two portions of the involved bone are separated by less than 1 cm.

What does Aetna exclude for Bone Growth Stimulators?

Policy exclusions and limitations: Ultrasonic osteogenesis stimulator is experimental/investigational for fractures (including lumbar compression fracture, stress fracture, and avulsion fracture of the hip), failed fusions, or non-unions of the axial skeleton (skull and vertebrae); Ultrasonic osteogenesis stimulator is experimental/investigational for avascular necrosis of the femoral head; Ultrasonic osteogenesis stimulator is experimental/investigational for calcaneal apophysitis (Sever disease); Ultrasonic osteogenesis stimulator is experimental/investigational for Charcot arthropathy; Ultrasonic osteogenesis stimulator is experimental/investigational for fractures with post-reduction displacement of more than 50% (opposing broken bone ends out of alignment by more than one half of the width of the bone); Ultrasonic osteogenesis stimulator is experimental/investigational for iliac apophysitis; Ultrasonic osteogenesis stimulator is experimental/investigational for pathological fractures due to malignancy (unless the neoplasm is in remission); Ultrasonic osteogenesis stimulator is experimental/investigational for pre-operative use for fractures that require surgical intervention or internal or external fixation; Ultrasonic osteogenesis stimulator is experimental/investigational for stress fractures; Ultrasonic osteogenesis stimulator is experimental/investigational for talar dome lesion following osteochondral autograft transfer system (OATS); Ultrasonic osteogenesis stimulator is experimental/investigational for all other indications not listed as covered (list not all-inclusive); the medical literature does not support its use; Electrical bone-growth stimulator is experimental/investigational for avascular necrosis of the hip; Electrical bone-growth stimulator is experimental/investigational for Charcot arthropathy; Electrical bone-growth stimulator is experimental/investigational for Charcot foot; Electrical bone-growth stimulator is experimental/investigational for comminuted toe fracture; Electrical bone-growth stimulator is experimental/investigational for fractures of the scapula or pelvis; Electrical bone-growth stimulator is experimental/investigational for loosened hip prosthesis; Electrical bone-growth stimulator is experimental/investigational for loosened knee prosthesis; Electrical bone-growth stimulator is experimental/investigational for lunate fractures; Electrical bone-growth stimulator is experimental/investigational for odontoid fractures; Electrical bone-growth stimulator is experimental/investigational for pre-operative use for fractures that require surgical intervention or internal or external fixation; Electrical bone-growth stimulator is experimental/investigational for sacroiliac fusion; Electrical bone-growth stimulator is experimental/investigational for spondylolysis (also known as pars inter-articularis fracture); Electrical bone-growth stimulator is experimental/investigational for stress fractures; Electrical bone-growth stimulator is experimental/investigational for all other indications not listed as covered (list not all-inclusive) due to lack of adequate evidence of effectiveness; Semi-invasive bone growth stimulators are experimental/investigational for ALL indications, including treatment of orthopedic and neurosurgical conditions (e.g., delayed unions, failed spinal fusions, fracture non-unions, fresh fractures, and pseudoarthroses), because of a lack of adequate evidence of their effectiveness. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT