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.
Invasive (inserted at the time of surgery) or noninvasive (beginning at any time from the time of surgery until up to 6 months after surgery) electrical bone growth stimulation may be considered medically necessary for spinal fusion surgery in individuals at high risk for pseudoarthroses with ONE or MORE of the following risk factors for fusion failure:
· One or more previously failed spinal fusion(s); or
· Multi-level lumbar/lumbosacral fusion including three (3) or more vertebrae; or
· Grade II or worse lumbar/lumbosacral spondylolisthesis; or
· History of current tobacco use; or
· Alcoholism; or
· Diabetes, renal disease, or other metabolic diseases when bone healing is likely to be compromised; or
· Nutritional deficiency/malnutrition; or
· Osteoporosis defined as a T-score of <-2.5 on a recent (within one year) DEXA; or
· Body Mass Index (BMI) greater than 30;or
· Severe anemia; or
· Glucocorticoid dependent.
Noninvasive electrical bone growth stimulation may be considered medically necessary as a treatment for individuals with failed spinal fusion when BOTH of the following criteria are met:
· A minimum of 6 months has passed since the date of the original surgery; and
radiographs or appropriate imaging studies confirm there is no evidence of
progression of healing/consolidation of the spinal fusion for 3 months during
the latter portion of the 6 month post-fusion surgery period.
Invasive and noninvasive electrical bone growth stimulation is considered experimental/investigational and therefore non-covered because the safety and effectiveness of this service cannot be established by the available published peer-reviewed literature for:
· Acute or chronic lumbar spondylolysis (pars interarticularis defect) with or without spondylolisthesis and as an adjunct to cervical fusion surgery; or
· Failed cervical spine fusion, or
· Failed cervical disc arthroplasty.
Semi-invasive electrical bone growth stimulation is considered experimental/investigational and therefore non-covered because the safety and effectiveness of this service cannot be established by the available published peer-reviewed literature.
Refer to medical policy E-35 Ultrasound Osteogenesis Stimulator for additional information.
Refer to medical policy S-89 Non-spinal Bone Growth Stimulation for additional information.
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.
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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.
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