Anthem Blue Cross Connecticut CG-DME-45 Ultrasound Bone Growth Stimulation Form
This procedure is not covered
This document addresses the use of low-intensity pulsed ultrasound devices as a non-invasive treatment to promote healing of some fresh fractures and to accelerate healing for nonunion of other fracture sites.
Note: Please refer to the following document for additional information related to devices used to stimulate bone growth:
- CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
Clinical Indications
Medically Necessary:
- Fresh Fractures
Non-invasive, low-intensity pulsed ultrasound treatment is considered medically necessary for the treatment of fresh fractures when any of the following are present:- Closed radial fractures, posteriorly displaced (Colles' fracture); or
- Tibial diaphyseal fractures that are either:
- Closed; or
- Grade I open; or
- Closed fracture sites at high risk for nonunion due to:
- Location; and
- Poor vascular supply, for example:
- Fractures of the carpal navicular bone (scaphoid fracture); or
- 5th metatarsal bone fractures (Jones fracture); or
- Fractures associated with:
- Extensive soft tissue; or
- Vascular damage; or
- Closed fractures at high risk for nonunion due to a comorbidity which makes healing likely to be compromised including any of the following:
- Diabetes; or
- Renal disease; or
- Other metabolic diseases; or
- History of tobacco use; or
- History of alcoholism; or
- Nutritional deficiency; or
- Obese individuals with:
- Body Mass Index (BMI) greater than 30; or
- When greater than 50% over ideal body weight (IBW);* or
- Severe anemia; or
- Steroid therapy.
- Fracture Nonunions
Non-invasive, low-intensity pulsed ultrasound treatment is considered medically necessary when all of the following criteria are met- Treatment for fracture nonunion of any bone of the appendicular skeleton ; and
- At least 45 days have passed since either of the following:
- The date of fracture; or
- The date of appropriate fracture care; and
- No progressive signs of healing have occurred on imaging studies (for example, bony bridging and callus formation); and
- Fracture gap is less than 1 centimeter.
Not Medically Necessary:
Non-invasive, low-intensity pulsed ultrasound treatment is considered not medically necessary when the above criteria are not met including, but not limited to, treatment of any of the following:
- As an adjunct to bunionectomy procedures at:
- The time of surgery; or
- Immediately after surgery;** or
- As an adjunct to distraction osteogenesis procedures for any indication, such as:
- Limb lengthening; or
- Nonunion corrective surgery; or
- Repair of tibial defects at either:
- The time of; or
- Immediately after surgery;** or
- Axial skeleton fractures including:
- Skull; and
- Vertebrae; or
- Congenital pseudoarthrosis; or
- Delayed fracture unions; or
- Fresh open fractures that either:
- Require surgical intervention;*** or
- Are too unstable for closed reduction/casting when either:
- Grade II; or
- Grade III open fractures; or
- Patellar tendinopathy; or
- Pathological fractures due to:
- Bone pathology; or
- Tumor/malignancy; or
- Stress fractures.
Notes:
*See Definitions section for calculation of ideal body weights (IBW).
**When surgical procedures result in nonunion the medically necessary criteria above may apply such as after:
- Bunionectomy; or
- Distraction osteogenesis.
***Fractures that are nonunion following surgical treatment should be considered for ultrasound bone growth stimulation applying the criteria under Fracture Nonunions in this document.