REVIEW REQUEST FOR
Ultrasound Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00027
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This medical policy based data collection tool is for medical necessity review for the use of lowintensity pulsed ultrasound devices as a treatment to promote healing of some fresh fractures and to
accelerate healing for nonunion of other fracture sites.
Read carefully and make your selection appropriately.
You MUST accurately complete this form specific to your request to facilitate your review request.
Please check all that apply to the individual:
Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fracture *
*NOTE: FRESH FRACTURE (a term for a fracture that has recently occurred, typically considered equal to or less than
seven days in duration, and has not had previous treatment, other than emergency splinting prior to evaluation and
fixation)
(If checked, mark all of the following that apply to the individual)
Individual has a closed radial fracture, posteriorly displaced (Colles')
Individual has a closed tibial diaphyseal fracture
Individual has a Grade I open tibial diaphyseal fracture
Individual has a closed fracture site at high risk for nonunion due to location and poor vascular supply (for
example, carpal navicular/scaphoid fractures, Jones/5th metatarsal fracture)
Individual has a closed fracture site at high risk for nonunion due to associated extensive soft tissue or vascular
damage
REVIEW REQUEST FOR
Ultrasound Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00027
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 12/12/2015
Individual has a closed fracture at high risk for nonunion due to a comorbidity:
(If checked, mark all of the following that apply to the individual)
Diabetes where bone healing is likely to be compromised
Renal disease where bone healing is likely to be compromised
A metabolic diseases where bone healing is likely to be compromised
History of tobacco use
History of alcoholism
Nutritional deficiency
The individual is obese with a Body Mass Index (BMI) greater than 30
The individual is obese and is greater than 50% over their ideal body weight (IBW)
Severe anemia
Steroid therapy
Other: ________________
Request is for non-invasive, low-intensity pulsed ultrasound treatment for fracture nonunion ** of the
appendicular skeleton (clavicle, humerus, radius, ulna, femur, fibula, tibia, carpal, metacarpal, tarsal, or
metatarsal)
**NOTE: FRACTURE NONUNIONS (a fracture in which all evidence of bone growth activity at the fracture site has
ceased, leaving a persistent unhealed fracture of the bone)
(If checked, mark all of the following that apply to the individual)
At least 45 days have passed since the date of fracture
At least 45 days have passed since the date of appropriate fracture care
Serial radiographs or appropriate imaging studies confirm there is no evidence of progression of healing
The fracture gap is less than one centimeter
Request is for non-invasive, low-intensity pulsed ultrasound treatment as an adjunct (at the time of or immediately after) to
a bunionectomy procedure
Request is for non-invasive, low-intensity pulsed ultrasound treatment as an adjunct (at the time of or immediately after)
to distraction osteogenesis procedures for any indication (for example, limb lengthening, nonunion or tibial defects)
Request is for non-invasive, low-intensity pulsed ultrasound treatment of axial skeleton fractures, including the skull and
vertebrae
Request is for non-invasive, low-intensity pulsed ultrasound treatment of congenital pseudoarthrosis
Request is for non-invasive, low-intensity pulsed ultrasound treatment for delayed fracture union
Request is for non-invasive, low-intensity pulsed ultrasound treatment for open Grade II fresh fractures
Request is for non-invasive, low-intensity pulsed ultrasound treatment for open Grade III fresh fractures
Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fractures that require surgical intervention
(with or without internal fixation)
Request is for non-invasive, low-intensity pulsed ultrasound treatment for fresh fractures that are too unstable for closed
reduction /casting
Request is for non-invasive, low-intensity pulsed ultrasound treatment for patellar tendinopathy
Request is for non-invasive, low-intensity pulsed ultrasound treatment for pathological fractures due to bone pathology
Request is for non-invasive, low-intensity pulsed ultrasound treatment pathological fractures due to tumor/malignancy
Request is for non-invasive, low-intensity pulsed ultrasound treatment for stress fractures
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REVIEW REQUEST FOR
Ultrasound Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00027
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 12/12/2015
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
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