Anthem Blue Cross Connecticut CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton Form

This document addresses the use noninvasive electrical bone growth stimulation devices for the treatment of orthopedic and neurosurgical conditions of the appendicular skeleton. This document does not address invasive electrical bone growth stimulation of any area of the body or noninvasive electrical bone growth stimulation of the spine.

Note: Please refer to the following document for additional information related to devices used to stimulate bone growth:

• CG-DME-45 Ultrasound Bone Growth Stimulation

Clinical Indications

Medically Necessary:

1. Noninvasive electrical bone growth stimulation is considered medically necessary when all of the following criteria are met: 
   1. Treatment is for either of the following:
      1. Fracture nonunion of any bone of the appendicular skeleton; or
      2. Congenital pseudoarthroses of any bone of the appendicular skeleton; and
   2. At least 45 days have passed since either of the following:
      1. The date of fracture; or
      2. The date of appropriate fracture care; and
   3. No progressive signs of healing have occurred on imaging studies (for example, bony bridging and callus formation); and
   4. The fracture gap is less than 1 centimeter.
2. Noninvasive electrical bone growth stimulation is considered medically necessary as a treatment for joint fusion secondary to failed arthrodesis of the ankle or knee.

Not Medically Necessary:

1. Noninvasive electrical bone growth stimulation of any bone of the appendicular skeleton is considered not medically necessary when either of the following contraindications is present:
   1. Draining osteomyelitis; or
   2. Synovial pseudoarthroses.
2. Noninvasive electrical bone growth stimulation of any bone of the appendicular skeleton is considered not medically necessary when the above criteria are not met, including, but not limited to treatment of any of the following:
   1. As an adjunct to (that is, at the time of or immediately after) bunionectomy procedures (Note: When such surgery results in nonunion, the medically necessary criteria above may apply); or
   2. As an adjunct to (that is, at the time of or immediately after) distraction osteogenesis procedures for any indication (for example, limb lengthening, nonunion, or tibial defects); or
   3. Delayed/incomplete union fractures; or
   4. Fresh fractures; or
   5. Patellar tendinopathy; or
   6. Pathological fractures due to bone pathology or tumor/malignancy; or
   7. Stress fractures.