Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electric osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve the electric osteogenesis stimulator. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the electric osteogenesis stimulator. Our 
reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found 
this 76-year-old female was being treated for status post cervical fusion. She is status post open repair 
fracture/subluxation C5/6 anterior cervical discectomy, right foraminotomy, interbody structural fusion and 
anterior plating C5/6 on October 2, 2021 and subtotal laminectomy C5, resection of torn ligament, partial right 
facetectomy, bilateral foraminotomies, posterior non-segmental instrumentation with posterior fusion at C5-6 
on October 5, 2021. She presented noting shoulder stiffness from wearing her cervical collar. Lately whenever 
she is laying down or getting up from bed, she will have dizziness, but goes away a few seconds later. Overall, 
she is doing well. The wound is nicely healed. Exam reveals she is in a cervical collar. Incisions healed well. 
Right forearm swelling is much better, still has some mild swelling in the right hand. Bilateral upper extremity 
range of motion is intact. Grasp strength is 4/5 on the right. The computed tomography (CT) scan of the 
cervical spine stated previous C5-6 anterior cervical fusion hardware again noted, stable appearance since prior 
study. Detailed documentation is not evident regarding any delayed healing of the cervical spine fusion. 
Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows this request 
to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested electric osteogenesis stimulator (E0748), in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electric osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the electric osteogenesis stimulator (E0748).