016.06.04 Ark. Code R. 083

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.04-083 - DMS-2004-R-20, DMS-2004-J-1: Exogen - Ultrasonic Osteogenic Stimulator for Treatment of Non-Union Fractures

Effective for dates of service on and after March 1, 2005, Arkansas Medicaid will cover ultrasonic osteogenic stimulator (Exogen) for the treatment of non-union fractures for all ages.

A. Prior authorization (PA) from the Utilization Review section of the Division of Medical Services will be required.

1. The PA process will be the same as for all durable medical equipment (DME) procedure codes that require PA. The patient's physician must prescribe the device and make a referral to the DME provider.

2. Prior authorization request requires documentation of the following:

a. A minimum of two sets of radiographs, separated by a minimum of 90 days, and obtained prior to starting treatment with the osteogenic stimulator.

b. Multiple views of the fracture site for each radiograph.

c. The physician's written statement that there has been no clinically significant evidence of fracture healing in the interval between the two sets of radiographs.

d. If the opposing surfaces of a fracture are greater than 5mm apart, then surgical intervention would be required prior to utilizing a bone stimulator.

3. Prior authorization of the device may be approved for up to 180 days. If the need for the device extends beyond 180 days, an additional PA is required. Documentation which includes updated evaluations must be submitted with the PA request.

B. Coverage of the device does not include:

1. Non-unions of the skull, vertebrae and those tumor-related.

2. Concurrent use with other non-invasive osteogenic devices.

C. Reimbursement is by capped rental rate. Procedure code E0760 must be used when filing claims along with the assigned PA number. Modifier NU must be used for patients ages 21 and older. Modifier EP must be used for patients under age 21.

When filing paper claims, type of service code "H" and modifier NU must be used for patients ages 21 and older. Type of service code "6" and modifier EP must be used for patients under age 21.

Thank you for your participation in the Arkansas Medicaid Program.

Roy Jeffus, Director

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016.06.04 Ark. Code R. 083

5/9/2005