An ultrasonic osteogenesis stimulator is a noninvasive device that emits low intensity, pulsed ultrasound. The ultrasound signal is applied to the skin surface at the fracture location via ultrasound conductive coupling gel to stimulate fracture healing.
An ultrasonic osteogenesis stimulator may be considered medically necessary when ALL of the following criteria are met:
20979 |
E0760 |
|
|
|
|
|
Fresh Closed Fractures
Low-intensity ultrasound accelerated fracture healing systems may be considered medically necessary as an adjunct to conventional management (i.e., closed reduction and cast immobilization) for the treatment of fresh newly diagnosed or recent fractures (up to fourteen (14) days after the fracture occurs), or closed fractures of a skeletally mature individual.
An individual who has been determined to be at high risk for delayed fracture healing or nonunion fractures, includes at least ONE of the following indications:
20979 |
E0760 |
|
|
|
|
|
Osteogenesis stimulators not meeting the criteria as indicated in this policy are considered not medically necessary. This includes, but is not limited to treatment of ANY of the following:
20970 |
E0760 |
|
|
|
|
|
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other noninvasive osteogenesis stimulators.
E0747 |
|
|
|
|
|
|
Refer to Medical Policy S-89, Non-spinal Bone Growth Stimulation, for additional information.
Covered diagnosis codes for procedure codes 20979 and E0760
E10.65 |
E10.9 |
E11.65 |
E11.9 |
E13.9 |
F10.20 |
F17.200 |
F17.201 |
F17.210 |
F17.211 |
F17.220 |
F17.221 |
F17.290 |
F17.291 |
M80.011K |
M80.012K |
M80.021K |
M80.022K |
M80.031K |
M80.032K |
M80.041K |
M80.042K |
M80.051K |
M80.052K |
M80.061K |
M80.062K |
M80.071K |
M80.072K |
M80.0AXG |
M80.0AXK |
M80.0B1A |
M80.0B1D |
M80.0B1G |
M80.0B1K |
M80.0B1P |
M80.0B1S |
M80.0B2A |
M80.0B2D |
M80.0B2G |
M80.0B2K |
M80.0B2P |
M80.0B2S |
M80.0B9A |
M80.0B9D |
M80.0B9G |
M80.0B9K |
M80.0B9P |
M80.0B9S |
M80.8B1A |
M80.8B1D |
M80.8B1G |
M80.8B1K |
M80.8B1P |
M80.8B1S |
M80.8B2A |
M80.8B2D |
M80.8B2G |
M80.8B2K |
M80.8B2P |
M80.8B2S |
M80.8B9A |
M80.8B9D |
M80.8B9G |
M80.8B9K |
M80.8B9P |
M80.8B9S |
M80.811K |
M80.812K |
M80.821K |
M80.822K |
M80.831K |
M80.832K |
M80.841K |
M80.842K |
M80.851K |
M80.852K |
M80.861K |
M80.862K |
M80.871K |
M80.872K |
M80.8AXG |
M80.8AXK |
M81.6 |
M84.411K |
M84.412K |
M84.421K |
M84.422K |
M84.431K |
M84.432K |
M84.433K |
M84.434K |
M84.441K |
M84.442K |
M84.444K |
M84.445K |
M84.451K |
M84.452K |
M84.454K |
M84.461K |
M84.462K |
M84.463K |
M84.464K |
M84.471K |
M84.472K |
M84.474K |
M84.475K |
M84.477K |
M84.478K |
M84.48XK |
M84.611K |
M84.612K |
M84.621K |
M84.622K |
M84.631K |
M84.632K |
M84.633K |
M84.634K |
M84.641K |
M84.642K |
M84.650K |
M84.651K |
M84.652K |
M84.661K |
M84.662K |
M84.663K |
M84.664K |
M84.671K |
M84.672K |
M84.674K |
M84.675K |
M84.754G |
M84.754K |
M84.755G |
M84.755K |
M84.756G |
M84.757G |
M84.757K |
M84.758G |
M84.758K |
N18.1 |
N18.2 |
N18.3 |
N18.30 |
N18.31 |
N18.32 |
N18.4 |
N18.5 |
N18.6 |
N18.9 |
S22.20XK |
S22.21XK |
S22.22XK |
S22.23XK |
S22.24XK |
S22.31XK |
S22.32XK |
S22.41XK |
S22.42XK |
S22.43XK |
S22.5XXK |
S22.9XXK |
S32.301K |
S32.302K |
S32.311K |
S32.312K |
S32.314K |
S32.315K |
S32.391K |
S32.392K |
S32.401K |
S32.402K |
S32.411K |
S32.412K |
S32.414K |
S32.415K |
S32.421K |
S32.422K |
S32.424K |
S32.425K |
S32.431K |
S32.432K |
S32.434K |
S32.435K |
S32.441K |
S32.442K |
S32.444K |
S32.445K |
S32.451K |
S32.452K |
S32.454K |
S32.455K |
S32.461K |
S32.462K |
S32.464K |
S32.465K |
S32.471K |
S32.472K |
S32.474K |
S32.475K |
S32.481K |
S32.482K |
S32.484K |
S32.485K |
S32.491K |
S32.492K |
S32.501K |
S32.502K |
S32.511K |
S32.512K |
S32.591K |
S32.592K |
S32.601K |
S32.602K |
S32.611K |
S32.612K |
S32.614K |
S32.615K |
S32.691K |
S32.692K |
S32.810K |
S32.811K |
S42.001K |
S42.002K |
S42.011K |
S42.012K |
S42.014K |
S42.015K |
S42.017K |
S42.018K |
S42.021K |
S42.022K |
S42.024K |
S42.025K |
S42.031K |
S42.032K |
S42.034K |
S42.035K |
S42.101K |
S42.102K |
S42.111K |
S42.112K |
S42.114K |
S42.115K |
S42.121K |
S42.122K |
S42.124K |
S42.125K |
S42.131K |
S42.132K |
S42.134K |
S42.135K |
S42.141K |
S42.142K |
S42.144K |
S42.145K |
S42.151K |
S42.152K |
S42.154K |
S42.155K |
S42.191K |
S42.192K |
S42.201K |
S42.202K |
S42.211K |
S42.212K |
S42.214K |
S42.215K |
S42.221K |
S42.222K |
S42.224K |
S42.225K |
S42.231K |
S42.232K |
S42.241K |
S42.242K |
S42.251K |
S42.252K |
S42.254K |
S42.255K |
S42.261K |
S42.262K |
S42.264K |
S42.265K |
S42.271K |
S42.272K |
S42.291K |
S42.292K |
S42.294K |
S42.295K |
S42.301K |
S42.302K |
S42.311K |
S42.312K |
S42.321K |
S42.322K |
S42.324K |
S42.325K |
S42.331K |
S42.332K |
S42.334K |
S42.335K |
S42.341K |
S42.342K |
S42.344K |
S42.345K |
S42.351K |
S42.352K |
S42.354K |
S42.355K |
S42.361K |
S42.362K |
S42.364K |
S42.365K |
S42.391K |
S42.392K |
S42.401K |
S42.402K |
S42.411K |
S42.412K |
S42.414K |
S42.415K |
S42.421K |
S42.422K |
S42.424K |
S42.425K |
S42.431K |
S42.432K |
S42.434K |
S42.435K |
S42.441K |
S42.442K |
S42.444K |
S42.445K |
S42.447K |
S42.448K |
S42.451K |
S42.452K |
S42.454K |
S42.455K |
S42.461K |
S42.462K |
S42.464K |
S42.465K |
S42.471K |
S42.472K |
S42.474K |
S42.475K |
S42.481K |
S42.482K |
S42.491K |
S42.492K |
S42.494K |
S42.495K |
S42.91XK |
S42.92XK |
S49.001K |
S49.002K |
S49.011K |
S49.012K |
S49.021K |
S49.022K |
S49.031K |
S49.032K |
S49.041K |
S49.042K |
S49.091K |
S49.092K |
S49.101K |
S49.102K |
S49.111K |
S49.112K |
S49.121K |
S49.122K |
S49.131K |
S49.132K |
S49.141K |
S49.142K |
S49.191K |
S49.192K |
S52.001K |
S52.001M |
S52.001N |
S52.002K |
S52.002M |
S52.002N |
S52.011K |
S52.012K |
S52.021K |
S52.021M |
S52.021N |
S52.022K |
S52.022M |
S52.022N |
S52.024K |
S52.024M |
S52.024N |
S52.025K |
S52.025M |
S52.025N |
S52.031K |
S52.031M |
S52.031N |
S52.032K |
S52.032M |
S52.032N |
S52.034K |
S52.034M |
S52.034N |
S52.035K |
S52.035M |
S52.035N |
S52.041K |
S52.041M |
S52.041N |
S52.042K |
S52.042M |
S52.042N |
S52.044K |
S52.044M |
S52.044N |
S52.045K |
S52.045M |
S52.045N |
S52.091K |
S52.091M |
S52.091N |
S52.092K |
S52.092M |
S52.092N |
S52.101K |
S52.101M |
S52.101N |
S52.102K |
S52.102M |
S52.102N |
S52.111K |
S52.112K |
S52.121K |
S52.121M |
S52.121N |
S52.122K |
S52.122M |
S52.122N |
S52.124K |
S52.124M |
S52.124N |
S52.125K |
S52.125M |
S52.125N |
S52.131K |
S52.131M |
S52.131N |
S52.132K |
S52.132M |
S52.132N |
S52.134K |
S52.134M |
S52.134N |
S52.135K |
S52.135M |
S52.135N |
S52.181K |
S52.181M |
S52.181N |
S52.182K |
S52.182M |
S52.182N |
S52.201K |
S52.201M |
S52.201N |
S52.202K |
S52.202M |
S52.202N |
S52.211K |
S52.212K |
S52.221K |
S52.221M |
S52.221N |
S52.222K |
S52.222M |
S52.222N |
S52.224K |
S52.224M |
S52.224N |
S52.225K |
S52.225M |
S52.225N |
S52.231K |
S52.231M |
S52.231N |
S52.232K |
S52.232M |
S52.232N |
S52.234K |
S52.234M |
S52.234N |
S52.235K |
S52.235M |
S52.235N |
S52.241K |
S52.241M |
S52.241N |
S52.242K |
S52.242M |
S52.242N |
S52.244K |
S52.244M |
S52.244N |
S52.245K |
S52.245M |
S52.245N |
S52.251K |
S52.251M |
S52.251N |
S52.252K |
S52.252M |
S52.252N |
S52.254K |
S52.254M |
S52.254N |
S52.255K |
S52.255M |
S52.255N |
S52.261K |
S52.261M |
S52.261N |
S52.262K |
S52.262M |
S52.262N |
S52.264K |
S52.264M |
S52.264N |
S52.265K |
S52.265M |
S52.265N |
S52.271K |
S52.271M |
S52.271N |
S52.272K |
S52.272M |
S52.272N |
S52.281K |
S52.281M |
S52.281N |
S52.282K |
S52.282M |
S52.282N |
S52.291K |
S52.291M |
S52.291N |
S52.292K |
S52.292M |
S52.292N |
S52.301K |
S52.301M |
S52.301N |
S52.302K |
S52.302M |
S52.302N |
S52.311K |
S52.312K |
S52.321K |
S52.321M |
S52.321N |
S52.322K |
S52.322M |
S52.322N |
S52.324K |
S52.324M |
S52.324N |
S52.325K |
S52.325M |
S52.325N |
S52.331K |
S52.331M |
S52.331N |
S52.332K |
S52.332M |
S52.332N |
S52.334K |
S52.334M |
S52.334N |
S52.335K |
S52.335M |
S52.335N |
S52.341K |
S52.341M |
S52.341N |
S52.342K |
S52.342M |
S52.342N |
S52.344K |
S52.344M |
S52.344N |
S52.345K |
S52.345M |
S52.345N |
S52.351K |
S52.351M |
S52.351N |
S52.352K |
S52.352M |
S52.352N |
S52.354K |
S52.354M |
S52.354N |
S52.355K |
S52.355M |
S52.355N |
S52.361K |
S52.361M |
S52.361N |
S52.362K |
S52.362M |
S52.362N |
S52.364K |
S52.364M |
S52.364N |
S52.365K |
S52.365M |
S52.365N |
S52.371K |
S52.371M |
S52.371N |
S52.372K |
S52.372M |
S52.372N |
S52.381K |
S52.381M |
S52.381N |
S52.382K |
S52.382M |
S52.382N |
S52.391K |
S52.391M |
S52.391N |
S52.392K |
S52.392M |
S52.392N |
S52.501K |
S52.501M |
S52.501N |
S52.502K |
S52.502M |
S52.502N |
S52.511K |
S52.511M |
S52.511N |
S52.512K |
S52.512M |
S52.512N |
S52.514K |
S52.514M |
S52.514N |
S52.515K |
S52.515M |
S52.515N |
S52.521K |
S52.522K |
S52.531K |
S52.531M |
S52.531N |
S52.532K |
S52.532M |
S52.532N |
S52.541K |
S52.541M |
S52.541N |
S52.542K |
S52.542M |
S52.542N |
S52.551K |
S52.551M |
S52.551N |
S52.552K |
S52.552M |
S52.552N |
S52.561K |
S52.561M |
S52.561N |
S52.562K |
S52.562M |
S52.562N |
S52.571K |
S52.571M |
S52.571N |
S52.572K |
S52.572M |
S52.572N |
S52.591K |
S52.591M |
S52.591N |
S52.592K |
S52.592M |
S52.592N |
S52.601K |
S52.601M |
S52.601N |
S52.602K |
S52.602M |
S52.602N |
S52.611K |
S52.611M |
S52.611N |
S52.612K |
S52.612M |
S52.612N |
S52.614K |
S52.614M |
S52.614N |
S52.615K |
S52.615M |
S52.615N |
S52.621K |
S52.622K |
S52.691K |
S52.691M |
S52.691N |
S52.692K |
S52.692M |
S52.692N |
S52.91XK |
S52.91XM |
S52.91XN |
S52.92XK |
S52.92XM |
S52.92XN |
S59.001K |
S59.002K |
S59.011K |
S59.012K |
S59.021K |
S59.022K |
S59.031K |
S59.032K |
S59.041K |
S59.042K |
S59.091K |
S59.092K |
S59.101K |
S59.102K |
S59.111K |
S59.112K |
S59.121K |
S59.122K |
S59.131K |
S59.132K |
S59.141K |
S59.142K |
S59.191K |
S59.192K |
S59.201K |
S59.202K |
S59.211K |
S59.212K |
S59.221K |
S59.222K |
S59.231K |
S59.232K |
S59.241K |
S59.242K |
S59.291K |
S59.292K |
S62.001A |
S62.001K |
S62.002A |
S62.002K |
S62.011A |
S62.011K |
S62.012A |
S62.012K |
S62.014A |
S62.014K |
S62.015A |
S62.015K |
S62.021A |
S62.021K |
S62.022A |
S62.022K |
S62.024A |
S62.024K |
S62.025A |
S62.025K |
S62.031A |
S62.031K |
S62.032A |
S62.032K |
S62.034A |
S62.034K |
S62.035A |
S62.035K |
S62.101K |
S62.102K |
S62.111K |
S62.112K |
S62.114K |
S62.115K |
S62.121K |
S62.122K |
S62.124K |
S62.125K |
S62.131K |
S62.132K |
S62.134K |
S62.135K |
S62.141K |
S62.142K |
S62.144K |
S62.145K |
S62.151K |
S62.152K |
S62.154K |
S62.155K |
S62.161K |
S62.162K |
S62.164K |
S62.165K |
S62.171K |
S62.172K |
S62.174K |
S62.175K |
S62.181K |
S62.182K |
S62.184K |
S62.185K |
S62.201K |
S62.202K |
S62.211K |
S62.212K |
S62.221K |
S62.222K |
S62.224K |
S62.225K |
S62.231K |
S62.232K |
S62.234K |
S62.235K |
S62.241K |
S62.242K |
S62.244K |
S62.245K |
S62.251K |
S62.252K |
S62.254K |
S62.255K |
S62.291K |
S62.292K |
S62.300K |
S62.301K |
S62.302K |
S62.303K |
S62.304K |
S62.305K |
S62.306K |
S62.307K |
S62.310K |
S62.311K |
S62.312K |
S62.313K |
S62.314K |
S62.315K |
S62.316K |
S62.317K |
S62.320K |
S62.321K |
S62.322K |
S62.323K |
S62.324K |
S62.325K |
S62.326K |
S62.327K |
S62.330K |
S62.331K |
S62.332K |
S62.333K |
S62.334K |
S62.335K |
S62.336K |
S62.337K |
S62.340K |
S62.341K |
S62.342K |
S62.343K |
S62.344K |
S62.345K |
S62.346K |
S62.347K |
S62.348K |
S62.349K |
S62.350K |
S62.351K |
S62.352K |
S62.353K |
S62.354K |
S62.355K |
S62.356K |
S62.357K |
S62.360K |
S62.361K |
S62.362K |
S62.363K |
S62.364K |
S62.365K |
S62.366K |
S62.367K |
S62.390K |
S62.391K |
S62.392K |
S62.393K |
S62.394K |
S62.395K |
S62.396K |
S62.397K |
S62.501K |
S62.502K |
S62.511K |
S62.512K |
S62.514K |
S62.515K |
S62.521K |
S62.522K |
S62.524K |
S62.525K |
S62.600K |
S62.601K |
S62.602K |
S62.603K |
S62.604K |
S62.605K |
S62.606K |
S62.607K |
S62.610K |
S62.611K |
S62.612K |
S62.613K |
S62.614K |
S62.615K |
S62.616K |
S62.617K |
S62.620K |
S62.621K |
S62.622K |
S62.623K |
S62.624K |
S62.625K |
S62.626K |
S62.627K |
S62.630K |
S62.631K |
S62.632K |
S62.633K |
S62.634K |
S62.635K |
S62.636K |
S62.637K |
S62.640K |
S62.641K |
S62.642K |
S62.643K |
S62.644K |
S62.645K |
S62.646K |
S62.647K |
S62.650K |
S62.651K |
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Z79.01 |
Z79.51 |
Z79.52 |
Z92.240 |
Z92.241 |
|
|
Use of an ultrasonic osteogenesis stimulator is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
