CG-DME-45 Ultrasound Bone Growth Stimulation

This policy addresses non-invasive, low-intensity pulsed ultrasound (LIPUS) bone growth stimulation for fracture healing. It is covered as medically necessary for fresh fractures when any of the following apply: closed, posteriorly displaced distal radius (Colles’) fractures; closed or Grade I open tibial diaphyseal fractures; or closed fractures at high risk for nonunion due to location/poor vascularity (e.g., scaphoid, Jones fractures), extensive soft-tissue/vascular damage, or comorbidities that impair healing (e.g., diabetes, renal/metabolic disease, tobacco or alcohol use, nutritional deficiency, obesity, severe anemia, steroid use). It is not covered when these criteria are not met, including use as an adjunct at the time of or immediately after bunionectomy, distraction osteogenesis (e.g., limb lengthening, nonunion corrective surgery), or repair of tibial defects.

"Fresh FracturesNon-invasive, low-intensity pulsed ultrasound treatment is consideredmedically necessaryfor the treatment of fresh fractures whenanyof the following are present:Closed radial fractur..."