Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.16 Osteogenic Stimulation : 2.2.16.3 Prior Authorization

2.2.16.3
Procedure codes E0747, E0748, E0749, and E0760 require prior authorization.
2.2.16.3.1 Noninvasive Electrical Osteogenic Stimulator
Procedure codes E0747 and E0748 may be prior authorized for the following conditions:
Nonunion of long bone fractures. Long bones include, but are not limited to, the humerus, femur, radius, ulna, tibia, fibula, clavicle, fifth metatarsal (when significant pain is present), carpal, and tarsal bones.
As an adjunct to spinal fusion surgery for clients who are at high-risk for pseudoarthrosis because of previously failed spinal fusion at the same site or for clients who are undergoing multiple level fusion. A multiple level fusion involves three or more vertebrae (e.g., L3-L5, L4-S1).
A noninvasive electrical osteogenic stimulator may be prior authorized when one of the following criteria is met:
There is no evidence of healing progression for six months or longer despite appropriate fracture care following a nonunion, failed fusion, or congenital pseudoarthrosis.
Serial radiographs have demonstrated that there is no evidence of healing progression after a delayed union of fracture or a failed arthrodesis. Serial radiographs must include a minimum of two sets of radiographs separated by a minimum of 90 days. Each set must include multiple views of the fracture site.
A radiograph demonstrates that the fracture gap is 1 cm or less, and the individual can be adequately immobilized and is likely to comply with non-weight-bearing requirements.
A multiple level fusion with extensive bone grafting is required, and other risk factors exist. Other risk factors include, but are not limited to, gross obesity, degenerative osteoarthritis, severe spondylolisthesis, current smoking, previous spinal fusion, previous disc surgery, or gross instability.
2.2.16.3.2 Invasive Electrical Osteogenic Stimulator
Procedure code E0749 may be prior authorized for the following conditions:
As an adjunct to spinal fusion surgery for clients who are at high-risk for pseudoarthrosis because of previously failed spinal fusion at the same site or for clients who are undergoing multiple level fusion. A multiple level fusion involves three or more vertebrae (e.g., L3–L5, L4–S1).
An invasive electrical osteogenic stimulator may be prior authorized when one of the following criteria is met:
Serial radiographs have demonstrated that there is no evidence of healing progression. Serial radiographs must include a minimum of two sets of radiographs separated by a minimum of 90 days. Each set must include multiple views of the fracture site.
2.2.16.3.3 Ultrasound Osteogenic Stimulator
Procedure code E0760 may be prior authorized when all of the following criteria are met:
Serial radiographs have demonstrated that there is no evidence of healing progression. Serial radiographs must include a minimum of two sets of radiographs separated by a minimum of 90 days. Each set must include multiple views of the fracture site.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.