CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton

This policy addresses noninvasive electrical bone growth stimulation devices for bones of the appendicular skeleton. Coverage is medically necessary for fracture nonunion or congenital pseudoarthrosis when at least 45 days have passed since the fracture or appropriate fracture care, imaging shows no progressive healing, and the fracture gap is less than 1 cm. It is not covered when contraindications (draining osteomyelitis, synovial pseudoarthroses) are present or when criteria are not met, including use as an adjunct at the time of bunionectomy or distraction osteogenesis, or for fresh fractures, delayed/incomplete unions, patellar tendinopathy, or pathologic fractures.

"Noninvasive electrical bone growth stimulation is consideredmedically necessarywhenallof the following criteria are met:Treatment is for either of the following:Fracture nonunion of any bone of the..."