REVIEW REQUEST FOR
Electrical Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00004
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 invasive,
noninvasive, and semi-invasive electrical bone growth stimulation devices.
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 invasive (inserted at time of surgery) electrical bone growth stimulation for spinal fusion surgery in
individuals at high risk for pseudoarthrosis
Request is for noninvasive (beginning from the time of surgery up to 6 months after surgery) electrical bone growth
stimulation for spinal fusion surgery in individuals at high risk for pseudoarthrosis
(If checked, please mark all of the following that apply to the individual)
One or more previous failed spinal fusion(s)
Grade III or worse spondylolisthesis
Fusion to be performed at more than one level
History of tobacco use
History of alcoholism
Diabetes where bone healing is likely to be compromised or growth is poor
Renal disease where bone healing is likely to be compromised or growth is poor
Metabolic disease where bone healing is likely to be compromised or growth is poor
(please list disease):
Nutritional deficiency
Obese individual with a Body Mass Index (BMI) greater than 30
Obese individual with greater than 50% over his/her ideal body weight (IBW)*
Severe anemia
Steroid therapy
Other (please list):
REVIEW REQUEST FOR
Electrical Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00004
Policy Last Review Date: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 12/12/2015
Request is for Noninvasive EBGS for individual with failed spinal fusion
(If checked, mark all of the following that apply):
A minimum of 6 months has passed since date of the original surgery
Serial x-rays or appropriate imaging studies show no progression of healing for 3 months
during the latter portion of the 6 month period
Other:
Request is for Noninvasive EBGS for fracture nonunion of long or short bones of the appendicular skeleton
Request is for Noninvasive EBGS for congenital pseudoarthroses of long or short bones of the appendicular skeleton:
(If checked, mark all of the following that apply)
At least 45 days have passed since date of fracture
At least 45 days have passed since the date of surgical treatment of fracture
Serial radiographs or appropriate imaging studies confirm no progressive signs of healing have occurred
Fracture gap is less than one centimeter
Other:
Request is for Noninvasive EBGS for treatment of joint fusion secondary to failed arthrodesis of the knee
Request is for Noninvasive EBGS for treatment of joint fusion secondary to failed arthrodesis of the ankle
Request is for Invasive electrical bone growth stimulation (EBGS) for any non-spinal indication
Request is for the Semi-Invasive electrical bone growth stimulation (EBGS) for an indication not specified
Please specify the indication: ___________________
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of synovial pseudoarthroses
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of draining osteomyelitis
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of fresh fractures
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of delayed/incomplete union
fractures
Request is for the Noninvasive electrical bone growth stimulation (EBGS) as an adjunct (that is, at the time of or
immediately after) to a bunionectomy procedure
Request is for the Noninvasive electrical bone growth stimulation (EBGS) as an adjunct (that is, 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 the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of patellar tendinopathy
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pathological fractures due to
bone pathology
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pathological fractures due to
tumor/malignancy
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of spondylolysis
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of pars interarticularis defect
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of stress fractures
Request is for the Noninvasive electrical bone growth stimulation (EBGS) for the treatment of any other condition:
Specify condition:
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REVIEW REQUEST FOR
Electrical Bone Growth Stimulation
Provider Data Collection Tool Based on Medical Policy DME.00004
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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