Does 20975 require prior authorization?

No, 20975 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 20975?

Medicare facility rate: $168.67. Non-facility rate: $168.67. Work RVU: 2.54.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.54

Facility

$168.67

Non-Facility

$168.67

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.

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; [...]

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

CIGNA-INVASIVE — Bone Growth Stimulators: Electrical (Invasive), Ultrasound - (0084)

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