Point32 Osteogenesis Stimulators(formally Electrical Bone Growth Stimulators) Form

Harvard Pilgrim HealthCare Medical Policy

Osteogenesis Stimulators

Subject: Osteogenesis Stimulators

Background: Osteogenesis Stimulator devices are a noninvasive alternative therapy to promote bone healing in fractures that have failed to heal on their own. The devices are designed to generate an electrical current to a fracture or bone fusion site to stimulate bone growth or osteogenesis. Osteogenesis stimulators are most effective in nonunion or delayed union fractures. Nonunion fractures are broken bones that fail to heal while delayed union fractures are broken bones that take more time than expected to heal. Bone growth stimulators are intended to be used as an adjunct to conventional interventions to fractures (e.g., cast immobilization, rest, or bracing).

Authorization: Prior authorization is required for covered electrical bone growth stimulators provided to members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Photographs— HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, Harvard Pilgrim Health Care (HPHC) draws upon the following InterQual® criteria:

• Osteogenesis Stimulator, Electrical Noninvasive, Not Spinal Applications (Version 2023)
• Osteogenesis Stimulator, Electrical Noninvasive, Spinal Applications (Version 2023)
• Osteogenesis Stimulator, Low Intensity Ultrasound, Noninvasive (Version 2023)

Exclusions: Harvard Pilgrim Health Care (HPHC) considers electrical bone growth stimulators as not medically necessary for all other indications.