20974
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.60
Facility
$50.77
Non-Facility
$95.19
Documentation Required
- Radiographic evidence of skeletal maturity (radiology report/images).
- For electrical stimulators used as adjunct to lumbar spinal fusion: documentation demonstrating increased risk for fusion failure, including one or more of the following: operative reports and dates showing previously failed fusion at the same site with a minimum of six months elapsed since the last surgical procedure; surgical plan or operative reports showing fusion performed or to be performed at more than one level as part of a single surgery; clinical history and problem list documenting comorbid conditions associated with compromised bone healing (e.g., diabetes, obesity, osteoporosis, current tobacco use); imaging or clinical documentation of spondylolisthesis grade II or greater.
- For ultrasonic stimulators for nonunion of long bones: documentation of fracture gap measurement demonstrating <= 1 cm (radiographic measurement); radiographic reports showing persistent fracture line without bridging callus present for 3 months or more (with dates); documentation that the fracture has been reduced and immobilized (operative/reduction notes, immobilization device records); operative reports showing date of most recent surgical operation (coverage requires < 6 months since most recent surgery); pathology/imaging or clinical notes documenting fracture is not pathological or associated with malignancy.
Key Coverage Criteria
- Invasive or Non-Invasive spinal Electrical Bone Growth Stimulator is proven and medically necessary as an adjunct to lumbar spinal fusion surgery when the following two criteria are met: Radiographic evidence of skeletal maturity; and Increased risk for fusion failure demonstrated by any of the following.
- Increased risk for fusion failure demonstrated by any of the following: Previously failed fusion at the same site, when minimum of six months has elapsed since the last surgical procedure.
- Increased risk for fusion failure demonstrated by any of the following: Spinal fusion performed or to be performed at more than one level as part of a single surgery.
- Increased risk for fusion failure demonstrated by any of the following: Comorbid conditions associated with compromised bone healing (e.g., diabetes, obesity, osteoporosis, current tobacco use).
- Increased risk for fusion failure demonstrated by any of the following: Spondylolisthesis grade II or greater.
- Ultrasonic Bone Growth Stimulators are proven and medically necessary for the treatment of Nonunion of long bone fractures when all of the following criteria are met: Fracture gap is less than or equal to 1 cm; Radiographic evidence of a persistent fracture line without bridging callus is present for 3 months or more; Fracture reduced and immobilized; Less than 6 months have passed since the date of most recent surgical operation; Fracture that is not pathological or associated with malignancy; [...]
16 Active Policies
AMBETTER-CP.MP.194 — Osteogenic Stimulation
UMR-POL-UMR-electrical-ultrasound-bone-growth-stimulators — Electrical and Ultrasonic Bone Growth Stimulators
SUREST-POL-SUREST-electrical-ultrasound-bone-growth-stimulators — Electrical and Ultrasonic Bone Growth Stimulators
CARELON-spine-surgery-2024-01-01 — Spine Surgery
Related Codes
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