BlueCross and BlueShield of Montana Medical Policy/Codes
Distraction Devices, External Fixation Devices, Bone Lengthening Devices
Chapter: Surgery: Procedures
Current Effective Date: October 25, 2013
Original Effective Date: October 25, 2013
Publish Date: July 25, 2013
Revised Dates: January 15, 2014
Description

In 1950 Dr. Gavriel Ilizarov developed an external orthopedic device to treat limb length discrepancies. The Ilizarov device, along with the development of other fixation devices has improved the outcomes of bone lengthening, and osteogenesis in skeletal deformities and injury.

Distraction osteogenesis involves surgical reconstruction of skeletal deformities. It involves the gradual displacement and repositioning of healthy bone into a previously deficient surgically created fracture and the simultaneous expansion of soft tissue and bone volume. The distraction device is then left in place to act as a fixation device. As a result of gradual distraction, the osseous and soft tissue components are enlarged in a single simultaneous process.    

At this time, in addition to the original Ilizarov external fixator, the Ilizarov system includes:

  • The Acute Trauma Ilizarov II ,which provides stability and versatility with increased ease of application in the acute trauma setting; or
  • The Hex Fix Ilizarov Hybrid Frame which, combines the versatility of the original Ilizarov with the simplicity of the Hex Fix system; or
  • The Ilizarov Small Bone Fixation System, which can be used for small, pediatric and upper extremity applications.
Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Musculoskeletal distraction devices, external fixation devices, and bone lengthening devices for lower limbs may be considered medically necessary in cases:

  • Demonstrating non-union or malunion of bones with or without bone loss or infection, or
  • Where lengthening of an amputation stump is needed for proper fitting of a prosthesis, or
  • Where leg lengthening is needed to equalize leg length discrepancy greater than 6 cm and to correct congenital or post traumatic angular/rotational deformations of the bones, or
  • When used for bone defects with or without deformities.

Use of a bone lengthening device for the upper extremities in the absence of congenital or post-traumatic limb length discrepancies and angular deformities is considered experimental, investigational and/or unproven.

The use of bone lengthening for the sole purpose of altering short stature is considered not medically necessary.

Rationale

A search of peer reviewed literature through October 2013 identified no additional published studies that would prompt reconsideration of the coverage statement, which remains unchanged. The literature continues to reveal that the Ilizarov device and other equivalent devices are effective and accepted for the correction of congenital or post-traumatic limb length discrepancies and angular deformities of the limb (arm, forearm, thigh, or leg). (1-6)

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

78.10, 78.12, 78.13, 78.15, 78.17, 78.32, 78.33, 78.35, 78.37, 736.09, 736.81, 736.89, 736.39,  755.24, 755.25, 755.26, 755.27, 755.34, 755.35, 755.36, 755.37, 755.59, 755.69

ICD-10 Codes

074.0, 072.70, 074.2

Procedural Codes: 20690, 20692, 20693, 20694, 20696, 20697
References
  1. Gugenheim JJ. The Ilizarov method. Orthopedic and soft tissue applications. Clin Plast Surg 1998; 25(4):567-78.
  2. Herbert AJ, Herzenberg JE, Paley D. A review for pediatricians on limb lengthening and the Ilizarov method. Curr Opin Pediatr 1995; 7(1):98-105.
  3. Tsuchiya H, Tomita K. Distraction osteogenesis for treatment of bone loss in the lower extremity. J Orthop Sci 2003; 8(1):116-24.
  4. DeCoster TA, Gehlert RJ, Mikola EA et al. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg 2004; 12(1):28-38.
  5. Ilizarov Bone-Lengthening Procedure – Archived. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (October 2009) Surgery 7.01.11.
  6. Shiha A, Hafez AR, et al. Salvage of complicated diaphyseal femoral fractures by 1-stage open debridement and Ilizarov technique Ann Plast Surg (2013 Nov) 71(5):519-21
History
July 2013  New 2013 BCBSMT medical policy.
January 2014 Document updated with literature review.  Coverage unchanged.
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Distraction Devices, External Fixation Devices, Bone Lengthening Devices