THIS IS NO LONGER AN ACTIVE POLICY. POLICY WAS ARCHIVED ON 06/16/2025.
Medical & Reimbursement Policies
Medical Policy
D-1149-002
Policy Id
HHO-DE-MP-1149
Topic
Nonspinal Bone Growth Stimulation
Section
Archived Policies
Effective Date
Jun 16, 2025
Issued Date
May 16, 2025
Last Revision Date
05/2025
Annual Review
05/2026
Prepared By
J Fletcher
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options services for Nonspinal Bone Growth Stimulation.
Definitions
Bone growth stimulation – Bone growth stimulation is also known as osteogenesis stimulation and is used when the body's healing process fails to heal bone injuries. The bone growth stimulation device stimulates the natural healing process of the bone by sending low-level pulses of electromagnetic energy to the injury site.
Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.
Policy Position
Prior Authorization
Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup
Procedures
Both invasive and noninvasive non spinal electrical bone growth stimulation are eligible for payment in the treatment of a nonunited fracture. A nonunited fracture is defined as a fracture that has not healed within a minimum of three (3) months of the original fracture.
Noninvasive, nonspinal electrical bone growth stimulation may be considered medically necessary as a treatment of fracture nonunion or congenital pseudoarthrosis in the appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper extremities, pelvis, and lower extremities). The diagnosis of fracture nonunion must meet ALL of the following criteria:
- At least three (3) months have passed since the date of the fracture; and
- Serial radiographs have confirmed that no progressive signs of healing have occurred; and
- The fracture gap is one (1) centimeter or less; and
- The individual can be adequately immobilized and is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of congenital pseudoarthrosis in the appendicular skeleton.
Noninvasive, non-spinal electrical bone growth stimulation may be considered medically necessary as a treatment of failed fusion of the appendicular skeleton when a minimum of nine (9) months has elapsed since the last surgical intervention.
Non-spinal Electrical Bone Growth Stimulation (EBGS) not meeting the criteria as indicated in this policy is considered not medically necessary.
References
Clinical Trials.gov. U. S. National Institutes of Health. A prospective clinical registry to collect patient outcomes for the BIOMET® EBI bone healing system, BIOMET® OrthoPak® noninvasive bone growth stimulator system, and the BIOMET® SpinalPak® noninvasive spine fusion stimulator system.
ECRI Institute. Electric bone growth stimulating devices for treating acute and nonunion bone fractures (custom rapid review). 2016. Available from: ECRI Institute, Plymouth Meeting (PA).
InterQual® Level of Care Criteria 2019, Acute Care Adult, McKesson Health Solutions, LLC; 2019.
Buza JA, 3rd, Einhorn T. Bone healing in 2016. Clin Cases Miner Bone Metab. 2016;13(2):101- 105.
Aleem IS, Aleem I, Evaniew N, et al. Efficacy of electrical stimulators for bone healing: A metaanalysis of randomized sham-controlled trials. Sci Rep. 2016; 6:31724.
Hayes, Inc. Health Technology Assessment. Noninvasive electrical bone growth stimulators for acute, delayed union, and nonunion fractures. Lansdale, PA: Hayes, Inc.; 06/30/2016.
Hayes, Inc. Hayes Health Technology Assessment. Electrical bone growth stimulation, invasive. Lansdale, PA: Hayes, Inc.; 07/21/2016.
Hayes, Inc. Hayes Health Technology Assessment. Noninvasive electrical bone growth stimulators for spinal fusion or foot and ankle indications. Lansdale, PA: Hayes, Inc.; 09/22/2016.
Aleem IS, Aleem I, Evaniew N, Busse JW, et al. Efficacy of electrical stimulators for bone healing: A meta-analysis of randomized sham-controlled trials. Sci Rep. 2016; 6:31724.
Murray HB, Pethica BA. A follow-up study of the in-practice results of pulsed electromagnetic field therapy in the management of nonunion fractures. Orthop Res Rev. 2016; 8:67-72.
