1.0 CPT PROCEDURE CODES
20670, 20680, 20974 - 20975, 20979
3.0 DESCRIPTION
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.
4.0 POLICY
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.