498 Form

Medical Policy Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures Table of Contents
• Policy: Commercial • Description
• Information Pertaining to All Policies
• Authorization Information • Policy History • References
• Coding Information

Policy Number: 498 BCBSA Reference Number: 7.01.85 (For Plan internal use only) NCD/LCD: NA Related Policies
• Ultrasound Accelerated Fracture Healing Device, #497 • Electrical Bone Growth Stimulation of the Appendicular Skeleton, #499 • Bone Morphogenetic Protein, #097 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Either invasive or noninvasive methods of electrical bone growth stimulation may be MEDICALLY NECESSARY as an adjunct to lumbar spinal fusion surgery in individuals at high risk for fusion failure, defined as any one of the following criteria:

• One or more previous failed spinal fusion(s), • Grade 3 or worse spondylolisthesis, • Fusion to be performed at more than 1 level, • Current tobacco use, • Diabetes, • Renal disease, • Alcoholism, and • Steroid use.

Noninvasive electrical bone stimulation may be MEDICALLY NECESSARY as a treatment of individuals with failed lumbar spinal fusion. Failed spinal fusion is defined as a spinal fusion that has not healed at a minimum of 6 months after the original surgery, as evidenced by serial x-rays over a course of 3 months.

Semi-invasive electrical stimulation is INVESTIGATIONAL as an adjunct to lumbar fusion surgery and for failed lumbar fusion.

Non-invasive electrical bone growth stimulation for treatments that do not meet the criteria noted above are INVESTIGATIONAL.

Invasive, semi-invasive, and noninvasive electrical stimulation are INVESTIGATIONAL as an adjunct to cervical fusion surgery and for failed cervical spine fusion.

Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 20974 Electrical stimulation to aid bone healing; noninvasive (non-operative)
20975 Electrical stimulation to aid bone healing; invasive (operative)

HCPCS Codes HCPCS codes:

Code Description E0749 Osteogenesis stimulator, electrical (surgically implanted

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

HCPCS Codes HCPCS codes:

Code Description E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications

The following ICD Diagnosis Codes are considered medically necessary when submitted with the HCPCS code above if medical necessity criteria are met:

ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description E10.10 Type 1 Diabetes Mellitus with Ketoacidosis Without Coma

E10.11 Type 1 Diabetes Mellitus With Ketoacidosis With Coma E10.21 Type 1 Diabetes Mellitus With Diabetic Nephropathy E10.22 Type 1 Diabetes Mellitus With Diabetic Chronic Kidney Disease E10.29 Type 1 Diabetes Mellitus With Other Diabetic Kidney Complication E10.311 Type 1 Diabetes Mellitus With Unspecified Diabetic Retinopathy With Macular Edema E10.319 Type 1 Diabetes Mellitus With Unspecified Diabetic Retinopathy Without Macular Edema E10.3211 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3212 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3213 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3219 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.3291 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3292 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3293 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3299 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.3311 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3312 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3313 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3319 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.3391 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3392 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3393 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3399 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.3411 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3412 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3413 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3419 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.3491 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3492 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3493 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3499 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye

E10.3511 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3512 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3513 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3519 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.3521 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Right Eye E10.3522 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Left Eye E10.3523 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Bilateral E10.3529 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Unspecified Eye E10.3531 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Right Eye E10.3532 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Left Eye E10.3533 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Bilateral E10.3539 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Unspecified Eye E10.3541 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Right Eye E10.3542 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Left Eye E10.3543 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Bilateral E10.3549 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Unspecified Eye E10.3551 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Right Eye E10.3552 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Left Eye E10.3553 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Bilateral E10.3559 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Unspecified Eye E10.3591 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3592 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3593 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3599 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.37X1 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Right Eye E10.37X2 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Left Eye E10.37X3 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Bilateral E10.37X9 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Unspecified Eye E10.39 Type 1 Diabetes Mellitus With Other Diabetic Ophthalmic Complication E10.40 Type 1 Diabetes Mellitus With Diabetic Neuropathy, Unspecified

E10.41 Type 1 Diabetes Mellitus With Diabetic Mononeuropathy E10.42 Type 1 Diabetes Mellitus With Diabetic Polyneuropathy E10.43 Type 1 Diabetes Mellitus With Diabetic Autonomic (Poly)Neuropathy E10.44 Type 1 Diabetes Mellitus With Diabetic Amyotrophy E10.49 Type 1 Diabetes Mellitus With Other Diabetic Neurological Complication E10.51 Type 1 Diabetes Mellitus With Diabetic Peripheral Angiopathy Without Gangrene E10.52 Type 1 Diabetes Mellitus With Diabetic Peripheral Angiopathy With Gangrene E10.59 Type 1 Diabetes Mellitus With Other Circulatory Complications E10.610 Type 1 Diabetes Mellitus With Diabetic Neuropathic Arthropathy E10.618 Type 1 Diabetes Mellitus With Other Diabetic Arthropathy E10.620 Type 1 Diabetes Mellitus With Diabetic Dermatitis E10.621 Type 1 Diabetes Mellitus With Foot Ulcer E10.622 Type 1 Diabetes Mellitus With Other Skin Ulcer E10.628 Type 1 Diabetes Mellitus With Other Skin Complications E10.630 Type 1 Diabetes Mellitus With Periodontal Disease E10.638 Type 1 Diabetes Mellitus With Other Oral Complications E10.641 Type 1 Diabetes Mellitus With Hypoglycemia With Coma E10.649 Type 1 Diabetes Mellitus With Hypoglycemia Without Coma E10.65 Type 1 Diabetes Mellitus With Hyperglycemia E10.69 Type 1 Diabetes Mellitus With Other Specified Complication E10.8 Type 1 Diabetes Mellitus With Unspecified Complications E10.9 Type 1 Diabetes Mellitus Without Complications E10.A0 Type 1 diabetes mellitus, presymptomatic, unspecified E10.A1 Type 1 diabetes mellitus, presymptomatic, Stage 1 E10.A2 Type 1 diabetes mellitus, presymptomatic, Stage 2 E11.00 Type 2 Diabetes Mellitus With Hyperosmolarity Without Nonketotic Hyperglycemic- Hyperosmolar Coma (Nkhhc) E11.01 Type 2 Diabetes Mellitus With Hyperosmolarity With Coma E11.10 Type 2 Diabetes Mellitus With Ketoacidosis Without Coma E11.11 Type 2 Diabetes Mellitus With Ketoacidosis With Coma E11.21 Type 2 Diabetes Mellitus With Diabetic Nephropathy E11.22 Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease E11.29 Type 2 Diabetes Mellitus With Other Diabetic Kidney Complication E11.311 Type 2 Diabetes Mellitus With Unspecified Diabetic Retinopathy With Macular Edema E11.319 Type 2 Diabetes Mellitus With Unspecified Diabetic Retinopathy Without Macular Edema E11.3211 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3212 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3213 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3219 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.3291 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3292 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3293 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3299 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.3311 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye

E11.3312 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3313 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3319 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.3391 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3392 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3393 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3399 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.3411 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3412 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3413 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3419 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.3491 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3492 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3493 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3499 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.3511 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3512 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3513 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3519 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.3521 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Right Eye E11.3522 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Left Eye E11.3523 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Bilateral E11.3529 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Unspecified Eye E11.3531 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Right Eye E11.3532 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Left Eye E11.3533 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Bilateral E11.3539 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Unspecified Eye E11.3541 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Right Eye

E11.3542 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Left Eye E11.3543 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Bilateral E11.3549 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Unspecified Eye E11.3551 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Right Eye E11.3552 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Left Eye E11.3553 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Bilateral E11.3559 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Unspecified Eye E11.3591 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3592 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3593 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3599 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.36 Type 2 Diabetes Mellitus With Diabetic Cataract E11.37X1 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Right Eye E11.37X2 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Left Eye E11.37X3 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Bilateral E11.37X9 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Unspecified Eye E11.39 Type 2 Diabetes Mellitus With Other Diabetic Ophthalmic Complication E11.40 Type 2 Diabetes Mellitus With Diabetic Neuropathy, Unspecified E11.41 Type 2 Diabetes Mellitus With Diabetic Mononeuropathy E11.42 Type 2 Diabetes Mellitus With Diabetic Polyneuropathy E11.43 Type 2 Diabetes Mellitus With Diabetic Autonomic (Poly)Neuropathy E11.44 Type 2 Diabetes Mellitus With Diabetic Amyotrophy E11.49 Type 2 Diabetes Mellitus With Other Diabetic Neurological Complication E11.51 Type 2 Diabetes Mellitus With Diabetic Peripheral Angiopathy Without Gangrene E11.52 Type 2 Diabetes Mellitus With Diabetic Peripheral Angiopathy With Gangrene E11.59 Type 2 Diabetes Mellitus With Other Circulatory Complications E11.610 Type 2 Diabetes Mellitus With Diabetic Neuropathic Arthropathy E11.618 Type 2 Diabetes Mellitus With Other Diabetic Arthropathy E11.620 Type 2 Diabetes Mellitus With Diabetic Dermatitis E11.621 Type 2 Diabetes Mellitus With Foot Ulcer E11.622 Type 2 Diabetes Mellitus With Other Skin Ulcer E11.628 Type 2 Diabetes Mellitus With Other Skin Complications E11.630 Type 2 Diabetes Mellitus With Periodontal Disease E11.638 Type 2 Diabetes Mellitus With Other Oral Complications E11.641 Type 2 Diabetes Mellitus With Hypoglycemia With Coma E11.649 Type 2 Diabetes Mellitus With Hypoglycemia Without Coma E11.65 Type 2 Diabetes Mellitus With Hyperglycemia E11.69 Type 2 Diabetes Mellitus With Other Specified Complication E11.8 Type 2 Diabetes Mellitus With Unspecified Complications E11.9 Type 2 Diabetes Mellitus Without Complications E11.A Type 2 diabetes mellitus without complications in remission F10.10 Alcohol abuse, uncomplicated

F10.11 Alcohol abuse, in remission F10.20 Alcohol dependence, uncomplicated F10.21 Alcohol dependence, in remission M43.15 Spondylolisthesis, thoracolumbar region M43.16 Spondylolisthesis, lumbar region M43.17 Spondylolisthesis, lumbosacral region M43.25 Fusion of spine, thoracolumbar region M43.26 Fusion of spine, lumbar region M43.27 Fusion of spine, lumbosacral region M96.0 Pseudarthrosis after fusion or arthrodesis N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.30 Chronic kidney disease, stage 3 unspecified N18.31 Chronic kidney disease, stage 3a N18.32 Chronic kidney disease, stage 3b N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified Z72.0 Tobacco use Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids

Description Electrical Bone Growth Stimulators Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to spinal fusion surgery, with or without associated instrumentation, to enhance the probability of obtaining a solid spinal fusion. Noninvasive devices have also been investigated to treat a failed fusion.

Electrical and electromagnetic fields can be generated and applied to bones through surgical, noninvasive, and semi-invasive methods.

Invasive Stimulators Invasive devices require surgical implantation of a current generator in an intramuscular or subcutaneous space, with an accompanying electrode implanted within the fragments of bone graft at the fusion site. The implantable device typically remains functional for 6 to 9 months after implantation. Although the current generator is removed in a second surgical procedure when stimulation is completed, the electrode may or may not be removed. Implantable electrodes provide constant stimulation at the nonunion or fracture site but carry increased risks associated with implantable leads.

Noninvasive Stimulators Noninvasive electrical bone growth stimulators generate a weak electrical current within the target site using either pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads/electrodes are placed on either side of the fusion site and are worn for 24 hours a day until healing occurs, or for up to 9 months. In contrast, pulsed electromagnetic fields are delivered via treatment coils that are placed into a back brace or directly onto the skin and are worn for 6 to 8 hours a day for 3 to 6 months. Combined magnetic fields deliver a time-varying magnetic field by superimposing the time-varying field onto an additional static magnetic field. This device involves 30 minutes of treatment daily for 9 months. Patient compliance may be an issue with externally worn devices.

Semi-Invasive Stimulators Semi-invasive (semi-implantable) stimulators use percutaneous electrodes and an external power supply, obviating the need for a surgical procedure to remove the generator when treatment is finished.

Summary

Description Both invasive and noninvasive electrical bone growth stimulators have been investigated as an adjunct to spinal fusion surgery, with or without associated instrumentation, to enhance the probability of obtaining a solid spinal fusion. Noninvasive devices have also been investigated in patients who are at normal risk of failed fusion and to treat a failed fusion.

Summary of Evidence For individuals who are at high-risk of lumbar spinal fusion surgery failure who receive invasive or noninvasive electrical bone growth stimulation, the evidence includes systematic reviews, a TEC Assessment, and randomized controlled trials (RCTs). Relevant outcomes are symptoms, change in disease status, and functional outcomes. Results from these trials have indicated that in patients with risk factors for failed fusion surgery, either invasive or noninvasive electrical bone stimulation increases the fusion rate. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have failed lumbar spinal fusion surgery who receive noninvasive electrical bone growth stimulation, the evidence includes a TEC Assessment and studies with patients serving as their own controls. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Data have shown that noninvasive electrical stimulation improves fusion rates in this population. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are undergoing cervical spinal fusion surgery or have failed cervical spine fusion who receive invasive or noninvasive electrical bone growth stimulation, the evidence includes a RCT. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The only controlled trial published to date had methodologic limitations, and the efficacy of electrical stimulation in the cervical spine has not been established. An open-label multicenter cohort study provided evidence to demonstrate that patients at high-risk for arthrodesis following anterior cervical discectomy and fusion procedures reported statistically significant improvements in fusion rates with pulsed electromagnetic field stimulation. However, limitations in the study design, including use of a historical control group, lack of blinding, and no restrictions on surgical methods used by surgeons, preclude definitive assessments of treatment efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 10/2025 Clarified coding information. 7/2025 Annual policy review. Summary and references updated. Policy statements unchanged. 10/2024 Clarified coding information. 6/2024 Annual policy review. References updated. Policy statements unchanged. 6/2023 Annual policy review. Minor editorial refinements to policy statements, intent unchanged 3/2023 Clarified coding information. 11/2022 Clarified coding information. 6/2022 Annual policy review. Policy statements unchanged. 5/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2017 Annual policy review. New references added. 5/2016 Annual policy review. New references added. 12/2014 Annual policy review. New references added. 12/2013 Added LCD: L11501 to the policy.

11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements. 6/2011 Reviewed - Medical Policy Group - Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 4/2011 Annual policy review. No changes to policy statements. 7/2010 Reviewed - Medical Policy Group - Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 12/2009 Annual policy review. Changes to policy statements. 7/2009 Reviewed - Medical Policy Group - Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 7/2008 Reviewed - Medical Policy Group - Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 7/2007 Reviewed - Medical Policy Group - Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 6/2007 Annual policy review. Changes to policy statements.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. U.S. Food and Drug Administration (FDA). Summary Minutes: Center for Devices and Radiological Health Orthopaedic and Rehabilitation Devices Panel. 2020. Accessed April 8, 2025.
2. Kucharzyk DW. A controlled prospective outcome study of implantable electrical stimulation with spinal instrumentation in a high-risk spinal fusion population. Spine (Phila Pa 1976). Mar 01 1999; 24(5): 465-8; discussion 469. PMID 10084185
3. Rogozinski A, Rogozinski C. Efficacy of implanted bone growth stimulation in instrumented lumbosacral spinal fusion. Spine (Phila Pa 1976). Nov 01 1996; 21(21): 2479-83. PMID 8923635
4. Andersen T, Christensen FB, Egund N, et al. The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 2: fusion rates. Spine (Phila Pa 1976). Oct 01 2009; 34(21): 2248-53. PMID 19934803
5. Andersen T, Christensen FB, Langdahl BL, et al. Fusion mass bone quality after uninstrumented spinal fusion in older patients. Eur Spine J. Dec 2010; 19(12): 2200-8. PMID 20429017
6. Akhter S, Qureshi AR, Aleem I, et al. Efficacy of Electrical Stimulation for Spinal Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sci Rep. Mar 12 2020; 10(1): 4568. PMID 32165697
7. Andersen T, Christensen FB, Ernst C, et al. The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 1: functional outcome. Spine (Phila Pa 1976). Oct 01 2009; 34(21): 2241-7. PMID 19934802
8. Foley KT, Mroz TE, Arnold PM, et al. Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion. Spine J. 2008; 8(3): 436-42. PMID 17983841
9. Goodwin CB, Brighton CT, Guyer RD, et al. A double-blind study of capacitively coupled electrical stimulation as an adjunct to lumbar spinal fusions. Spine (Phila Pa 1976). Jul 01 1999; 24(13): 1349- 56; discussion 1357. PMID 10404578
10. Jenis LG, An HS, Stein R, et al. Prospective comparison of the effect of direct current electrical stimulation and pulsed electromagnetic fields on instrumented posterolateral lumbar arthrodesis. J Spinal Disord. Aug 2000; 13(4): 290-6. PMID 10941887
11. Kane WJ. Direct current electrical bone growth stimulation for spinal fusion. Spine (Phila Pa 1976). Mar 1988; 13(3): 363-5. PMID 3291140
12. Linovitz RJ, Pathria M, Bernhardt M, et al. Combined magnetic fields accelerate and increase spine fusion: a double-blind, randomized, placebo controlled study. Spine (Phila Pa 1976). Jul 01 2002; 27(13): 1383-9; discussion 1389. PMID 12131732

13. Mooney V. A randomized double-blind prospective study of the efficacy of pulsed electromagnetic fields for interbody lumbar fusions. Spine (Phila Pa 1976). Jul 1990; 15(7): 708-12. PMID 2218718
14. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Electrical bone growth stimulation in association with spinal fusion surgery (noninvasive method). TEC Evaluations. 1993:1-
16. U.S. Food and Drug Administration. Summary of Safety and Effectiveness Data: Cervical-Stim Model 505L Cervical Fusion System. 2004. Accessed April 9, 2025.
17. Coric D, Bullard DE, Patel VV, et al. Pulsed electromagnetic field stimulation may improve fusion rates in cervical arthrodesis in high-risk populations. Bone Joint Res. Feb 2018; 7(2): 124-130. PMID 29437635
18. North American Spine Society (NASS). NASS Coverage Policy Recommendations: Electrical Stimulation for Bone Healing (2016). Accessed April 7, 2025.
19. Kaiser MG, Eck JC, Groff MW, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: bone growth stimulators as an adjunct for lumbar fusion. J Neurosurg Spine. Jul 2014; 21(1): 133-9. PMID 24980594
20. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: bone growth stimulators and lumbar fusion. J Neurosurg Spine. Jun 2005; 2(6): 737-40. PMID 16028745
21. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Osteogenic Stimulators (150.2). 2005. Accessed April 6, 2025.