| Coverage Policy Manual | |
| Policy #: | 1997057 |
| Category: | Medicine |
| Initiated: | September 1993 |
| Last Review: | January 2024 |
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| Bone Growth Stimulation, Electrical, Appendicular Skeleton | |
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| Description: |
In the appendicular skeleton, electrical stimulation with either implantable electrodes or non-invasive surface stimulators has been investigated to facilitate the healing of fresh fractures, stress fractures, delayed union, nonunion, congenital pseudarthrosis, and arthrodesis.
No consensus on the definition of fracture nonunion currently exists. One proposed definition is failure of progression of fracture healing for at least 3 consecutive months (and for at least 6 months following the fracture), accompanied by clinical symptoms of delayed union or nonunion (pain, difficulty bearing weight) (Bhandari, 2012).
The original U.S. Food and Drug Administration (FDA) labeling of fracture nonunions defined them as fractures not showing progressive healing after at least 9 months from the original injury. The labeling states: "A nonunion is considered to be established when a minimum of 9 months has elapsed since injury and the fracture site shows no visibly progressive signs of healing for minimum of 3 months." This time frame is not based on physiologic principles, but was included as part of the research design for FDA approval as a means of ensuring homogeneous populations of patients, many of whom were serving as their own controls. Others have contended that 9 months represents an arbitrary cut-off point that does not reflect the complicated variables present in fractures, i.e., degree of soft tissue damage, alignment of the bone fragments, vascularity, and quality of the underlying bone stock. Some fractures may show no signs of healing, based on serial radiographs as early as 3 months, while a fracture nonunion may not be diagnosed in others until well after 9 months. The current policy of requiring a 3-month timeframe for lack of progression of healing is consistent with the definition of nonunion as described in the clinical literature.
Delayed union refers to a decelerating bone healing process, as identified in serial radiographs, together with a lack of clinical and radiologic evidence of union, bony continuity, or bone reaction at the fracture site for no less than 3 months from the index injury or the most recent intervention. In contrast, nonunion serial radiographs (described above) show no evidence of healing When lumped together, delayed union and nonunion are sometimes referred to as "ununited fractures."
A fracture is most commonly defined as “fresh” for 7 days after its occurrence. Most fresh closed fractures heal without complications with the use of standard fracture care (ie, closed reduction, cast immobilization).
Individuals with recognized delayed fracture unions might begin by reducing the risk factors for delayed unions or nonunions but may progress to surgical repair if it persists.
Different applications of electrical and electromagnetic fields have been used to promote healing of delayed and nonunion fractures: invasive, noninvasive, and semi-invasive.
Invasive stimulation involves the surgical implantation of a cathode at the fracture site to produce direct current electrical stimulation. Invasive devices require surgical implantation of a current generator in an intramuscular or subcutaneous space, while an electrode is implanted within the fragments of bone graft at the fusion site. The implantable device typically remains functional for 6 to 9 months after implantation, and although the current generator is removed in a second surgical procedure when stimulation is completed, the electrode may or may not be removed. Implantable electrodes provide constant stimulation at the nonunion or fracture site but carry increased risks associated with implantable leads.
Noninvasive electrical bone growth stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads/electrodes are placed on either side of the fusion site and worn for 24 hours a day until healing occurs or up to 9 months. In contrast, pulsed electromagnetic fields are delivered via treatment coils placed over the skin and worn for 6 to 8 hours a day for 3 to 6 months. Combined magnetic fields deliver a time-varying magnetic field by superimposing the time-varying magnetic field onto an additional static magnetic field. This device involves a 30-minute treatment per day for 9 months. Patient compliance may be an issue with externally worn devices.
Semi-invasive (semi-implantable) stimulators use percutaneous electrodes and an external power supply, obviating the need for a surgical procedure to remove the generator when treatment is finished.
Regulatory Status
In 1984, the noninvasive OrthoPak® Bone Growth Stimulator (BioElectron, now Zimmer Biomet) was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process for treatment of fracture nonunion. Pulsed electromagnetic field systems with the FDA premarket approval (all noninvasive devices) include Physio-Stim® (Orthofix), first approved in 1986, and OrthoLogic® 1000, approved in 1997, both indicated for the treatment of established nonunion secondary to trauma, excluding vertebrae and all flat bones, in which the width of the nonunion defect is less than one-half the width of the bone to be treated; and the EBI Bone Healing System® (Electrobiology, now Zimmer Biomet), which was first approved in 1979 and indicated for nonunions, failed fusions, and congenital pseudarthrosis. No distinction was made between long and short bones. The FDA has approved labeling changes for electrical bone growth stimulators that remove any time frame for the diagnosis. As of September 2020, under consideration is the reclassification of noninvasive electrical bone growth stimulators from Class III to the lower-risk Class II category (FDA, 2021).
No semi-invasive electrical bone growth stimulator devices were identified with FDA approval or clearance.
Electrical bone growth stimulators used as an adjunct to spinal fusion surgery are discussed in policy # 2009048.
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Policy/ Coverage: |
Effective, November 2009
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Noninvasive electrical bone growth stimulation meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
The following applications of electrical bone growth stimulation do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:
For members with contracts without primary coverage criteria, the following applications of electrical bone growth stimulation are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Semi-invasive, invasive or implantable electrical bone growth stimulators for any condition do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, semi-invasive, invasive or implantable electrical bone growth stimulators, for any condition, are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective, June 2000-October 2009
Noninvasive electrical bone growth stimulation meets primary coverage criteria for effectiveness and is covered for:
Noninvasive electrical bone growth stimulation for any other condition is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, noninvasive electrical bone growth stimulation for any other condition is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
Either the invasive and the noninvasive method may be covered when used as an adjunct to spinal fusion surgery, for patients at high risk for pseudarthrosis, including the following:
The following applications of electrical bone growth stimulation, all methods:
are not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, the following applications of electrical bone growth stimulation, all methods:
are considered not medically necessary. Medically unnecessary services are an exclusion in the member certificate of coverage.
The following applications of invasive and semi-invasive bone growth stimulation:
are not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, the following applications of invasive and semi-invasive bone growth stimulation:
are considered not medically necessary. Medically unnecessary services are an exclusion in the member certificate of coverage.
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| Rationale: |
The policy regarding electrical bone stimulation as a treatment of nonunion of fractures of the appendicular skeleton is based on the FDA-labeled indications. The FDA approval was based on a number of case series in which patients with nonunions, primarily of the tibia, served as their own control. These studies suggest that electrical stimulation results in subsequent unions in a significant percentage of patients. It should be noted that the labeled indications include nonunions or congenital pseudoarthroses of bones of the appendicular skeleton. No distinction is made between long and short bones. The original FDA labeling of fracture nonunions defined nonunions as those fractures that had not shown progressive healing after at least 9 months from the original injury. This time frame is not based on physiologic principles, but was included as part of the research design for FDA approval as a means of ensuring homogeneous populations of patients, many of whom were serving as their own controls. As mentioned above, the presence of a nonunion is related to a variety of factors, such as fracture type and location, degree of soft tissue damage, vascularization, and bone stock. Some fractures may show no signs of healing, based on serial radiographs, as early as 3 months, while a fracture nonunion may not be diagnosed in others until well after 9 months. At the present time, the FDA has approved labeling changes for electrical bone growth stimulators that remove any time frame for the diagnosis. The current policy of requiring a 3-month time frame is still arbitrary, but appears to be consistent with the definition of nonunion, as described in the clinical literature.
While data from a double-blind randomized controlled clinical trial (and additional long-term outcome data provided by the investigator) of patients with delayed unions suggests that a 12 week course of noninvasive electrical bone stimulation is associated with a significantly higher healing rate than a control group with a dummy device, there are inadequate data regarding the final health outcome of the patient, i.e., regained use of limb, minimal pain, avoidance of subsequent surgery. All patients in the trial had an unhealed fracture at an average of 23.8 weeks after injury; all fracture gaps were under 0.5 cm. In terms of long-term outcome, a significantly greater proportion of the treated patients avoided any further surgery.
2002 Update
A literature search of the MEDLINE database was performed for the period of 1998 to September 2002. The search focused in particular on citations addressing the use of noninvasive electrical stimulation for delayed unions. No additional controlled trials were identified.
2009 Update
A literature search of the MEDLINE database was conducted through November 2009.
A 2008 systematic review by Griffin and colleagues included 49 studies, 3 of which were randomized controlled trials (Griffin, 2008). The first, a double-blind randomized controlled trial (RCT) by Sharrard, compared pulsed electromagnet field (PEMF) stimulation with a sham procedure using a dummy device, in 45 patients with nonunion of the tibia (Sharrard, 2009). Stimulators were positioned on the surface of the plaster cast. Treatment began 16 to 32 weeks after injury. Patients with fracture gaps greater than 0.5 cm after reduction, systemic disease, or taking steroids were excluded as well as patients with marked bony atrophy or hypertrophy. Fifty-one patients were recruited, and 45 completed the protocol. In the treatment group, 3 patients achieved union, 2 achieved probable union, 5 showed progression to union, and 10 showed no progress after 12 weeks. In the control group, none had united, one had probably united, 3 progressed toward union, and 17 showed no progress. Scott and King compared PEMF with sham treatment in 23 patients with nonunion (fracture at least 9 months old and without clinical or radiographic sign of progression to union within the last 3 months) of a long bone (Scott, 1994). Patients with systemic bone disorders, synovial pseudoarthrosis, or fracture gap of greater than half the width of the bone were excluded. In this trial, electrodes were passed onto the skin surface through holes in the plaster cast. Twenty-one patients completed the protocol (10 treatment and 11 controls). Six months after beginning treatment, an orthopedic surgeon and a radiologist, neither of them involved in the patients’ management, examined radiographs and determined that 6 of 10 in the treatment group healed, while none of those in the control group healed (p=0.004). Simonis et al compared PEMF and placebo treatment for tibial shaft fractures un-united at least a year after fracture, no metal implant bridging the fracture gap, and no radiological progression of healing in the 3 months before treatment (Simonis, 2003). All 34 patients received operative treatment with osteotomy and unilateral external fixator prior to randomization. Treatment was delivered by external coils. Patients were assessed monthly for 6 months, and clinical and radiographic assessments were conducted at 6 months. Treatment was considered a failure if union was not achieved at 6 months. In the treatment group, 89% of fractures healed compared with 50% in the control group. While a larger percentage of smokers in the treatment group healed than compared with those in the control group, the number of smokers in each group was not comparable, and the difference in healing rates between groups was not statistically significant. The authors conclude that the available evidence supports the use of PEMF in the treatment of nonunion of the tibia and suggest that future trials should consider which modality of electromagnetic stimulation and in which anatomical sites the treatment is most effective.
No studies of semi-invasive (semi-implantable) stimulators were identified during the most recent literature search of MEDLINE through November 2009. In addition, none of these devices has FDA clearance or approval. There is a lack of scientific evidence that the use of semi-invasive stimulators improve health outcomes for any indication.
2012 Update
A search of the MEDLINE database was conducted through September 2012. One multicenter, double-blind, randomized sham-controlled trial was identified which evaluated 12 weeks of pulsed electromagnetic field stimulation for acute tibial shaft fractures (Adie, 2011). The endpoints examined were secondary surgical interventions, radiographic union, and patient-reported functional outcomes. Approximately 45% of patients were compliant with treatment (>6 hours daily use), and 218 patients (84% of 259) completed the 12-month follow-up. The primary outcome, the proportion of participants requiring a secondary surgical intervention because of delayed union or nonunion within 12 months after the injury, was similar for the 2 groups (15% active; 13% sham). Per protocol analysis comparing patients who actually received the prescribed dose of pulsed electromagnetic field stimulation versus sham treatment also showed no significant difference between groups. Secondary outcomes, which included surgical intervention for any reason (29% active; 27% sham), radiographic union at 6 months (66% active; 71% sham), and the SF-36 Physical Component Summary (44.9 active; 48.0 sham) and Lower Extremity Functional Scales at 12 months (48.9 active; 54.3 sham), also did not differ significantly between the groups. This sham-controlled RCT does not support a benefit for electromagnetic stimulation as an adjunctive treatment for acute tibial shaft fractures. The results of this trial does not prompt a change in the coverage statement.
2014 Update
A literature search was conducted through December 2013. Randomized trials were identified in the treatment of delayed union of fractures and stress fractures. The policy statement is changed to add a non-coverage statement for the treatment of stress fractures based on the recently published results summarized below.
Delayed Union
Shi et al. reported a randomized sham-controlled trial that included 58 patients with delayed union of surgically-reduced long-bone fractures (femur, tibia, humerus, radius or ulna) (Shi, 2013). Delayed union was defined as a failure to heal after at least 16 weeks and not more than 9 months following surgical reduction and fixation of the fracture. Patients with fracture nonunion, defined as failure to heal after more than 9 months, were excluded from the study. Treatment with 8 hours of PEMF per day was stopped when no radiographic progression was observed over 3 months or when union was achieved, with union defined as no pain during joint stressing or during motion at the fracture site and callus bridging for 3 out of 4 cortices on blinded assessment. Three months of treatment resulted in a slight, but not statistically significant, improvement in the rate of union between PEMF-treated patients and controls (38.7% vs. 22.2%). The success rate was significantly greater with PEMF (77.4% vs. 48.1%) after an average of 4.8 months of treatment. The time to union was not significantly different between PEMF (4.8 months, range, 2 to 12) and sham controls (4.4 months, range 2 to 7). Additional study is needed to permit greater certainty regarding the effect of this technology on delayed unions.
Stress Fractures
In 2008, Beck et al. reported a well-conducted randomized controlled trial (n=44) of capacitively coupled electric fields (OrthoPak) for healing acute tibial stress fractures (Beck, 2008). Patients were instructed to use the device for 15 hours each day and usage was monitored electronically. Healing was confirmed when hopping 10 cm high for 30 seconds was accomplished without pain. Although an increase in the hours of use per day was associated with a reduction in the time to healing, there was no difference in the rate of healing between treatment and placebo. Power analysis indicated that this number of patients was sufficient to detect a difference in healing time of 3 weeks, which was considered to be a clinically significant effect. Other analyses, which suggested that electrical stimulation might be effective for the radiologic healing of more severe stress fractures, were preliminary and a beneficial effect was not observed for clinical healing. There is insufficient evidence to permit conclusions regarding the efficacy of noninvasive electrical bone growth stimulation for treatment of stress fractures or delayed union, or following surgery of the appendicular skeleton.
2015 Update
A literature search conducted through December 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Updated 2014 guidelines from the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (AANS/CNS) state that there is no evidence published after their 2005 guidelines that conflicts with the previous recommendations regarding bone growth stimulation (Kaiser, 2014). Based on a single level II study from 2009, the routine use of direct current stimulation (DCS) in patients over the age of 60 years was not recommended. Use of DCS was recommended as an option for patients younger than 60 years of age, based on Level III and IV studies showing a positive impact on fusion rate. However, comments regarding the level III study were that it was a poorly designed and conducted cohort study consisting of an exceedingly small heterogeneous population of patients, and the overall recommendation was level C. There was insufficient evidence to recommend for or against the use of pulsed electromagnetic field stimulation (PEMFS) as a treatment alternative to revision surgery in patients presenting with pseudoarthrosis following posterolateral lumbar fusion (PLF, single level IV study). No additional studies investigating the efficacy of capacitive coupled electrical stimulation were identified.
2017 Update
A literature search conducted through January 2017 did not reveal any new information that would prompt a change in the coverage statement.
2018 Update
A literature search conducted using the MEDLINE database did not reveal any new literature that would prompt a change in the coverage statement.
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2019. No new literature was identified that would prompt a change in the coverage statement.
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2019. No new literature was identified that would prompt a change in the coverage statement.
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2020. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2021. No new literature was identified that would prompt a change in the coverage statement.
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2022. No new literature was identified that would prompt a change in the coverage statement.
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2023. No new literature was identified that would prompt a change in the coverage statement.
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| References: |
1993 Blue Cross Blue Shield Association Technology Evaluation Center Assessment; p 332-51. Adie S, Harris IA, Naylor JM et al.(2011) Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial. J Bone Joint Surg Am 2011; 93(17):1569-76. Aleem IS, Aleem I, Evaniew N, et al.(2016) Efficacy of electrical stimulators for bone healing: a meta-analysis of randomized sham-controlled trials. Sci Rep. Aug 19 2016;6:31724. Am Academy of Orthopaedic Surgeons Annual Meeting, March 15 to March 19, 2000. http://www.aaos.org/wordhtl/anmt2000/poster/pe183.htm. Accessed July 17 2000. Bassett CAL.(1993) Beneficial Effects of Electromagnetic Fields. J Cellular Biochemistry 1993; 51:387-393. Beck BR, Matheson GO, Bergman G et al.(2008) Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med 2008; 36(3):545-53. Bhandari M, Fong K, Sprague S, et al.(2012) Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am. Aug 1 2012;94(15):e1091-1096. Buza JA, 3rd, Einhorn T.(2016) Bone healing in 2016. Clin Cases Miner Bone Metab. May-Aug 2016;13(2):101-105. Electrical stimulation for fracture healing (#CAG-00043). http:///www.hcfa.gov/coverage/8b3-j2htm. Accessed July 18 1999. Faldini C, Cadossi M, Luciani D, et al.(2010) Electromagnetic bone growth stimulation in patients with femoral neck fractures treated with screws: prospective randomized double-blind study. Curr Orthop Pract. 2010;21(3):282-287. FDA.(2001) Center for Devices and Radiological Health (CDRH). Premarket approval. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm. Accessed July 20, 2001. Goodwin CB, Brighton CT, Guyer RD, et al.(1999) A double blind study of capacitively coupled electrical stimulation as an adjunct to lumbar spinal fusions. Spine 1999; 24:1349-1357. Gossling HR, Bernstein RA, Abbott J.(1992) Treatment of ununited tibial fractures: a comparison of surgery and pulsed electromagnetic fields (PEMF). Orthopedics 1992; 15:711-719. Griffin XL, Warner F, Costa M.(2008) The role of electromagnetic stimulation in the management of established non-union of long bone fractures: what is the evidence? Injury 2008; 39(4):419-29. Hannemann PF, Essers BA, Schots JP, et al.(2015) Functional outcome and cost-effectiveness of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a cost-utility analysis. BMC Musculoskelet Disord. Apr 11 2015;16:84. Hannemann PF, Gottgens KW, van Wely BJ et al.(2012) The clinical and radiological outcome of pulsed electromagnetic field treatment for acute scaphoid fractures: a randomised double-blind placebo-controlled multicentre trial. J Bone Joint Surg Br 2012; 94(10):1403-8. Hannemann PF, Gottgens KW, van Wely BJ, et al.(2012) The clinical and radiological outcome of pulsed electromagnetic field treatment for acute scaphoid fractures: a randomised double-blind placebo-controlled multicentre trial. J Bone Joint Surg Br. Oct 2012;94(10):1403-1408. Heckman JD, Ryaby JP, McCabe J, et al.(1994) Acceleration of Tibial Fracture Healing by Non Invasive, Low Intensity Pulsed Ultrasound. J Bone Jt Surg 1994; 76A:26-34. Holmes GB.(1994) Treatment of Delayed Unions and Nonunions of the Proximal Fifth Metatarsal with Pulsed Electromagnetic Fields. Foot Ankle Int 1994; 15:552-556. Hotta SS.(1994) Electrical Bone-Growth Stimulation and Spinal Fusion. AHCPR 1994; http://hstat.nlm.nih.gov/tempfiles/is/tempDI38840.html. Accessed January 31. Jenis LG, An HS, Stein R, et al.(2000) Prospective comparison of the effect of direct current electrical stimulation and pulsed electromagnetic fields on instrumented posterolateral lumbar arthrodesis. J Spinal Disord 2000; 13:290-296. Kahanovitz N.(1996) The use of adjunctive electrical stimulation to enhance the healing of spine fusions. Spine 1996; 21:2523-2525. Kaiser MG, Eck JC, Groff MW, et al.(2014) Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: bone growth stimulators as an adjunct for lumbar fusion. J Neurosurg Spine. Jul 2014;21(1):133-139. PMID 24980594 Mammi GI, Rocchi R, Cadossi R, et al.(1993) The electrical stimulation of tibial osteotomies: double-blind study. Clin Orthop 1993; 288:246-253. Martinez-Rondanelli A, Martinez JP, Moncada ME, et al.(2014) Electromagnetic stimulation as coadjuvant in the healing of diaphyseal femoral fractures: a randomized controlled trial. Colomb Med (Cali). Apr-Jun 2014;45(2):67-71. Mont MA, Tomek IM, Hungerford DS.(1997) Core decompression for avascular necrosis of the distal femur: long term followup. Clin Orthop 1997; 334:124-130. Oishi M, Onesti ST.(2000) Electrical bone graft stimulation for spinal fusion: a review. Neurosurg 2000; 47:1041-1055. Osteogenic Stimulation. Coverage issues manual. Medical procedures. http://www.hcfa.gov/pubforms/06_cim/ci35.htm#_1_53. Accessed July 18, 2001. Ryaby JT.(1998) Clinical effects of electromagnetic and electric fields on fracture healing. Clin Orthop 1998; 355S:S205-S215. Scott G, King JB.(1994) A prospective, double blind trial of electrical capacitive coupling in the treatment of non-union of long bones. J Bone Jt Surg 1994; 76A:820-826. Sharrard WJ.(2009) A double-blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. J Bone Joint Surg Br 2009; 72(3):347-55. Shi HF, Xiong J, Chen YX et al.(2013) Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study. BMC Musculoskelet Disord 2013; 14:35. Shi HF, Xiong J, Chen YX, et al.(2013) Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study. BMC Musculoskelet Disord. 2013;14:35. Simonis RB, Parnell EJ, Ray PS et al.(2003) Electrical treatment of tibial non-union: a prospective, randomized, double-blind trial. . Injury 2003; 34(5):357-62. Tejano NA, Puno R, Ignacio JM.(1996) The use of implantable direct current stimulation in multilevel spinal fusion without instrumentation. Spine 1996; 21:1904-1908. U.S. Food and Drug Administration (FDA).(2020) Summary Minutes: Center for Devices and Radiological Health Orthopaedic and Rehabilitation Devices Panel. 2020; https://www.fda.gov/media/145157/download. Accessed March 8, 2021. Van Laere C, Mulier M, Simon JP, et al.(1998) Core decompression for avascular necrosis of the femoral head. Acta Orthop Belg 1998; 64:269-272. Zamora-Navas P, Borras Verdera A, Lorenzo RA, et al.(1995) Electrical stimulation of bone nonunion with the presence of a gap. Acta Orthop Belg 1995; 61:169-176. |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association. |
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