Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Broken Bones (Hand)
Treatment: Durable Medical Equipment (bone growth stimulator, E0747 x [times] 1)
The insurer denied the Durable Medical Equipment (bone growth stimulator, E0747 x 1).
The denial is overturned.

The patient is an adult male. There is a denial letter/final adverse determination that states the provider asked for a bone growth stimulator for a broken bone in the hand. The letter states the criteria from the guideline titled "Bone Growth Stimulators, Electrical and Electromagnetic" must be met for approval. Based on the information provided, the criteria were not met and the letter states this type of care is only covered after a certain kind of surgery in the lower back with a risk factor for fusion failure. The records do not show that the patient had this kind of spine surgery or had any of the risk factors. The policy statement on noninvasive electrical bone growth stimulators is provided for review. Per the physician appeal letter from one of the patient's doctors, the patient has a nonunion of the left scaphoid. The physician states this is the best option for care for the patient at this time because of the nonunion fracture that has developed and the financial hardship the patient has. The patient has only recently acquired insurance. The other option of surgery is not in the best interest of the patient at this time, again, because of financial hardship.

There is a certificate of medical necessity. It states there has been no clinically significant healing for 90 days. The device is not being ordered as a treatment for a failed single level spinal fusion surgery. It states there has been at least one open surgical intervention for treatment of the fracture.

The office note reports the patient is an adult male with left wrist pain. There was a left wrist injury following an all-terrain vehicle (ATV) injury. The patient was diagnosed with a scaphoid waist fracture. He underwent open reduction and internal fixation (ORIF) with distal radius bone grafting. The patient was placed in a brace. X-rays have shown persistent lucency across the fracture site. Computed tomography (CT) scan demonstrated a delayed union with a lucency across the fracture site. The patient was having minimal pain in the left wrist; the only discomfort was with certain motions. A bone stimulator was recommended.

The proposed treatment was medically necessary.

Based on the records provided, it has been three months since the patient sustained the fracture. There is nothing to suggest the patient cannot be adequately mobilized. The fracture gap is one centimeter or less. A CT of the left wrist was performed, which showed a suspected nonunion of the navicular. There is persistent fraction margins and lucency about the screw highly suspicious for nonunion. This was compared to the CT scan of 4 months prior. It is greater than 90 days between the studies and there is no progression of healing. The procedure is in accordance with the generally accepted standards of medical practice. The patient has a documented nonunion of the navicular. This is seen on consecutive CT scans. The patient has undergone surgical intervention and a period of immobilization. The generally accepted standards of medical practice would be to try further noninvasive modalities to achieve fracture healing prior to proceeding with surgery. This is reflected in the policy cited below. The procedure is clinically appropriate, in terms of its type, frequency, extent, site, and duration and considered effective for the patient's injury and pathology. The patient meets the criteria for approval of the noninvasive electrical bone growth stimulator per the policy that is provided from the health care plan. The non-spinal portion of the policy was applied for this patient.