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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 6.2
Bone Growth Stimulation
Issue Date:  October 6, 1988
Authority:  32 CFR 199.4(c)(2)(i)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-1, March 10, 2017
20670, 20680, 20974 - 20975, 20979
E0747 - E0749, E0760
Electrical stimulation to augment bone repair can be accomplished through one of the following methods:
3.1  A totally invasive method in which electrodes and power pack are surgically implanted within the extremity.
3.2  A semi-invasive method in which electrodes penetrate the fracture and the power pack is externally placed and the leads are connected to the inserted electrodes.
3.3  A totally noninvasive method in which the electrodes are placed over the cast surface and are connected to an external power pack.
4.1  Use of the invasive and semi-invasive types of devices are covered for nonunion of long bone fractures.
4.2  Use of the noninvasive type of device is covered for the following procedures:
•  Nonunion of long bone fractures.
•  Failed fusion.
•  Congenital pseudo-arthroses.
4.3  Use of the invasive or noninvasive type of device is covered as an adjunct to spinal fusions to increase the probability of fusion success for:
4.3.1  Patients at high risk for pseudo-arthrosis, including those patients with:
•  One or more failed fusions;
•  Grade 2 or 3 spondylolisthesis;
•  Fusions at more than one level, or
4.3.2  Fusions performed on patients considered to be at high risk (i.e., smokers, obese, etc.).
4.4  Nonunion, for all types of devices. A nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing.
4.5  Ultrasound bone growth stimulators (CPT procedure code 20979) are covered when medically necessary and appropriate (e.g., as a treatment to promote healing of some fresh fractures and to accelerate healing for nonunion of other fracture sites). See Chapter 8, Section 5.1 for TRICARE policy on medical devices.
4.6  When determined to be medically necessary, the electrical bone stimulator may be rented following the Durable Medical Equipment (DME) reimbursement procedures outlined in Chapter 8, Section 2.1.
4.7  When determined to be medically necessary, repairs, adjustments and accessories necessary for the effective functioning of the device, and removal and replacement of the covered device, as well as associated surgical costs are covered.
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