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29.2.9.4 Prior Authorization Requirements for Bone Growth Stimulators
Prior authorization is required for bone growth stimulator devices. Inpatient admissions and ambulatory or day surgery require prior authorization.
Documentation of the following is required for prior authorization of the external, low-intensity ultrasound osteogenic device (procedure code E0760):
• Nonunion of a fracture other than the skull or vertebrae in a skeletally mature person, documented by a minimum of 2 sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days each, including multiple views of the fracture site, and with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the 2 sets of radiographs
•The fracture is not tumor-related
•The client has one of the following types of fresh (i.e., less than 7 days) fractures:
•Closed or grade I open, tibial diaphyseal fractures
•Closed fractures of the distal radius (Colles fracture)
Documentation of the following is required for prior authorization of the external, electromagnetic bone stimulator device (procedure code E0747):
•At least one of the following conditions:
•There is no evidence of progression for 3 months or longer despite appropriate fracture care following a nonunion, failed fusion, or congenital pseudarthrosis
•The client has delayed unions of fractures of failed arthrodesis at high-risk sites (i.e., open or segmental tibial fractures, carpal navicular fractures)
•At least one of the following criteria:
•Serial radiographs have confirmed that no progressive signs of healing have occurred
•The fractured gap is 1 cm or less
•The individual can be adequately immobilized and is likely to comply with nonweight bearing
Documentation of the following is required for prior authorization of the external, electromagnetic bone stimulator device for spinal application (procedure code E0748):
•One or more failed fusions
•Grade II or worse spondylolisthesis
•A multiple level fusion with extensive bone grafting is required
•Other risk factors for fusion failure are present, including gross obesity, degenerative osteoarthritis, severe spondylolisthesis, current smoking, previous fusion surgery, previous disc surgery, or gross instability
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