E0749, Osteogenesis stimulator, electrical, surgically implanted
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
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.
- Medical record documentation sufficient to verify the member meets the specific clinical criteria in the policy (e.g., imaging, operative notes, clinical notes, problem list, comorbidity documentation).
- Member-specific benefit plan document should be referenced as benefit coverage is determined by the member specific plan and applicable laws (documentation that service is covered by the member's plan may be required).
- Medicare requires that each radiograph set include multiple views of the fracture site accompanied by a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.
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; [...]
18 Active Policies
ANTHEM-CG-DME-40, CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
UHC-POL-electrical-ultrasound-bone-growth-stimulators, Electrical and Ultrasonic Bone Growth Stimulators
AETNA-CPB-0343, Bone Growth Stimulators
AMBETTER-CP.MP.194, Osteogenic Stimulation
SUR705.044, Electrical Bone Growth Stimulation of the Appendicular Skeleton
SUR705.013, Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
BCBSIL-SUR705.044, Electrical Bone Growth Stimulation of the Appendicular Skeleton
BCBSIL-SUR705.013, Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
BCBSMT-SUR705.044, Electrical Bone Growth Stimulation of the Appendicular Skeleton
BCBSMT-SUR705.013, Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
BCBSNM-SUR705.044, Electrical Bone Growth Stimulation of the Appendicular Skeleton
BCBSNM-SUR705.013, Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
BCBSOK-SUR705.044, Electrical Bone Growth Stimulation of the Appendicular Skeleton
BCBSOK-SUR705.013, Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
REGENCE-DME83.11, Electrical Bone Growth Stimulators (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
EVICORE-HPLAN-THE_HEALTH_PLAN-9FFECA62F018, The Health Plan Spine Surgery Code List - Effective 01/01/2026
Related Codes
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