Talar dome lesion following osteochondral autograft transfer system (OATS).įootnotes* Grade I indicates that skin opening is 1 cm or less and minimal muscle contusion.įor the treatment of all other indications, including the following (not an all-inclusive list) because of a lack of adequate evidence for these conditions:.Pre-operative use for fractures that require surgical intervention or internal or external fixation.
Pathological fractures due to malignancy (unless the neoplasm is in remission).Fractures with post-reduction displacement of more than 50% (i.e., fractures in which the opposing broken bone ends are out of alignment by more than one half of the width of the bone).Avascular necrosis of the femoral head.For all other indications, including the following (not an all-inclusive list) because the medical literature does not support its use for these indications:.For fractures (including lumbar compression fracture, stress fracture and avulsion fracture of the hip), failed fusions, or non-unions of the axial skeleton (skull and vertebrae).The following bone growth stimulators are considered experimental and investigational for the specified indications because their effectiveness for these indications has not been established: Grade II or worse spondylolisthesis, or.A multiple level fusion entailing 3 or more vertebrae (e.g., 元 to L5, L4 to S1, etc.), or.Direct current electrical bone-growth stimulators, as well as inductive coupling or capacitive coupling non-invasive electrical stimulators for any of the following spinal indications:.Non-unions, failed fusions, and congenital pseudarthrosis where there is no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care, and.Delayed unions of fractures or failed arthrodesis at high-risk sites (e.g., open or segmental tibial fractures, carpal navicular fractures, 5th metatarsal fractures, distal radius, and sesamoid bones (fibular sesamoid in the foot), or Delayed unions of fractures or failed arthrodesis at high-risk sites (e.g., open or segmental tibial fractures, carpal navicular fractures, 5th metatarsal fractures, distal radius, and sesamoid bones (fibular sesamoid in the foot), orA.Direct current electrical bone-growth stimulators, as well as inductive coupling or capacitive coupling non-invasive electrical stimulators for any of the following non-spinal indications:.The two portions of the involved bone are separated by less than 1 centimeter (cm).Bone is stable on both ends by means of cast or fixation and.An ultrasonic osteogenesis stimulator for non-unions, failed arthrodesis, and congenital pseudarthrosis (pseudoarthrosis) of the appendicular skeleton if there has been no X-ray evidence of progression of healing for 3 or more months despite appropriate fracture care, and the following criteria are met:.Fractures on these sites are difficult to heal because of poor vascular supply. This system uses pulsed ultrasound to speed healing. Fresh fractures, fusions, or delayed unions of the distal radius (Colles fracture) treated with closed reduction and cast immobilization.Fresh fractures, fusions, or delayed unions of the 5th metatarsal (Jones fracture) or.Fresh fractures, fusions, or delayed unions of the scaphoid (carpal navicular) or.Fresh closed or grade I Footnotes* open, short oblique or short spiral fractures, fusions, or delayed unions of the shaft (diaphysis) of the tibia that are treated with closed reduction and cast immobilization or.The use of an ultrasonic osteogenesis stimulator (e.g., an ultrasonic accelerated fracture healing device) as durable medical equipment (DME) to accelerate healing of fresh fractures, fusions, or delayed unions at any of the following high-risk sites:.This Clinical Policy Bulletin addresses bone growth stimulators.Īetna considers the following bone growth stimulators medically necessary: Number: 0343 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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