Protocol. Ultrasound Accelerated Fracture Healing Device

Transcription

1 Protocol Ultrasound Accelerated Fracture Healing Device (10105) Medical Benefit Effective Date: 04/01/14 Next Review Date: 01/17 Preauthorization Yes Review Dates: 09/07, 09/08, 09/09, 05/10, 05/11, 01/12, 01/13, 01/14, 01/15, 01/16 Preauthorization is required. The following Protocol contains medical necessity criteria that apply for this service. The criteria are also applicable to services provided in the local Medicare Advantage operating area for those members, unless separate Medicare Advantage criteria are indicated. If the criteria are not met, reimbursement will be denied and the patient cannot be billed. Please note that payment for covered services is subject to eligibility and the limitations noted in the patient s contract at the time the services are rendered. Description Low-intensity pulsed ultrasound (US) has been investigated as a technique to accelerate healing of fresh fractures, delayed unions, and nonunions. US is delivered with the use of a transducer applied to the skin surface overlying the fracture site. Summary of Evidence There is evidence from published studies that US improves healing rates in closed fresh fractures, delayed union, and fracture nonunion. As a result, US may be considered medically necessary for these indications. For treatment of open, fresh fractures, the evidence is less consistent across randomized controlled trials, and systematic reviews do not report strong conclusions on efficacy of US for improving healing when data on closed and open fresh fractures are combined. Most fresh closed fractures heal without complications with the use of standard fracture care, i.e., closed reduction and cast immobilization. Therefore, the most appropriate candidates for US treatment may be those with closed fractures at high risk for delayed fracture healing or nonunion. Based on the available evidence and support from clinical input, low-intensity US treatment may be considered medically necessary for fresh fractures (closed), delayed union of fractures, and nonunion of fractures. Evidence is insufficient to evaluate health outcomes with use of low-intensity US as a treatment of congenital pseudarthroses, arthrodesis of the appendicular skeleton, or spinal fusions. Use of US for these conditions is considered investigational. Based on one small trial with results showing no benefit to use of US treatment in the treatment of stress fractures, this is considered investigational. Policy Low-intensity ultrasound treatment may be considered medically necessary when used as an adjunct to conventional management (i.e., closed reduction and cast immobilization) for the treatment of fresh, closed fractures in skeletally mature individuals. Candidates for ultrasound treatment are those at high risk for delayed fracture healing or nonunion. These risk factors may include either locations of fractures or patient comorbidities and include the following: Page 1 of 6

2 Patient comorbidities: Diabetes Steroid therapy Osteoporosis History of alcoholism History of smoking Fracture locations: Jones fracture Fracture of navicular bone in the wrist (also called the scaphoid) Fracture of metatarsal Fractures associated with extensive soft tissue or vascular damage. Low-intensity ultrasound treatment may be considered medically necessary as a treatment of delayed union of bones, including delayed union of previously surgically-treated fractures, and excluding the skull and vertebra. (See Policy Guidelines for definition of delayed union.) Low-intensity ultrasound treatment may be considered medically necessary as a treatment of fracture nonunions of bones, including nonunion of previously surgically treated fractures, and excluding the skull and vertebra. (See Policy Guidelines for definition of nonunion.) Other applications of low-intensity ultrasound treatment are investigational, including, but not limited to, treatment of congenital pseudarthroses, open fractures, fresh surgically-treated closed fractures, stress fractures, arthrodesis or failed arthrodesis. Policy Guidelines Fresh (Acute) Fractures There is no standard definition for a fresh fracture. A fracture is most commonly defined as fresh for seven days after the fracture occurs, 1-3 but there is variability. For example, one study defined fresh as less than five days after fracture, 4 while another defined fresh as up to 10 days after fracture. 5 Most fresh closed fractures heal without complications with the use of standard fracture care, i.e., closed reduction and cast immobilization. Delayed Union Delayed union is defined as a decelerating healing process as determined by 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 three months from the index injury or the most recent intervention. Nonunions There is not a consensus for the definition of nonunions. One proposed definition is failure of progression of fracture-healing for at least three consecutive months (and at least six months following the fracture) accompanied by clinical symptoms of delayed/nonunion (pain, difficulty weight bearing). 6 The definition of non-union in the U.S. Food and Drug Administration (FDA) labeling suggests that nonunion is considered established when the fracture site shows no visibly progressive signs of healing, without giving any guidance regarding the timeframe of observation. However, it is suggested that a reasonable time period for lack of visible signs of healing is three months. The following patient selection criteria are consistent with those Page 2 of 6

3 proposed for electrical stimulation as a treatment of nonunions (see the Electrical Bone Growth Stimulation of the Appendicular Skeleton Protocol): At least three months have passed since the date of the fracture, AND serial radiographs have confirmed that no progressive signs of healing have occurred, AND the fracture gap is 1 cm or less, AND the patient can be adequately immobilized and is of an age when he/she is likely to comply with nonweight bearing. Medicare Advantage For Medicare Advantage ultrasonic osteogenic stimulators are medically necessary for the treatment of nonunion fractures prior to surgical intervention or after a failed surgical intervention. A nonunion fracture is demonstrated by: A minimum of two sets of radiographs, obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days. Each radiograph set must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs. It is not medically necessary to use ultrasonic osteogenic stimulators concurrently with other non-invasive osteogenic devices. Ultrasonic osteogenic stimulators for fresh fractures and delayed unions, and fractures of the skull, vertebrae or related to a tumor are not medically necessary. Background Most bone fractures heal spontaneously over the course of several months following injury. However, approximately 5% to 10% of all fractures have delayed healing, resulting in continued morbidity and increased utilization of health care services. US may accelerate healing of fractures by stimulating new bone growth, and therefore, has been proposed as a treatment for fractures with delayed healing or at high risk for nonhealing. The current protocol does not limit the use of the device to specific fracture sites. Depending on their function, bones are composed of a varying combination of cortical and trabecular bone. However, at the cellular level, the type of bone cannot be distinguished histologically. The inclusion of all bones regardless of the anatomic site is based on this histologic similarity of all bones; it is not anticipated that the efficacy of US-accelerated healing would vary according to the anatomic site and function of the bone. The definition of a fracture nonunion has remained controversial. For electrical bone growth stimulators (see the Electrical Bone Growth Stimulation of the Appendicular Skeleton Protocol), FDA labeling defined nonunion as follows: A nonunion is considered to be established when a minimum of nine months has elapsed since injury and the fracture site shows no visibly progressive signs of healing for minimum of three months. Others have contended that nine months represents an arbitrary cutoff point that does not reflect the complicated variables that are present in fractures, i.e., degree of soft tissue damage, alignment of the bone fragments, vascularity, and quality of the underlying bone stock. Other proposed definitions of nonunion involve three to six months time from original healing, or simply when serial radiographs fail to show any further healing. According to FDA labeling for a low-intensity pulsed US device, a nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing. Page 3 of 6

4 Delayed union is generally considered a failure to heal between three and nine months after fracture, after which the fracture site would be considered to be a nonunion. Delayed union may also be defined as a decelerating bone healing process, as identified in serial radiographs. (In contrast, nonunion serial radiographs show no evidence of healing.) Together, delayed union and nonunion are sometimes referred to as ununited fractures. To determine the status of fracture healing, it is important to include both radiographic and clinical criteria. Clinical criteria include the lack of ability to bear weight, fracture pain, and tenderness on palpation. Ultrasound treatment can be self-administered with one daily 20-minute treatment, continuing until the fracture has healed. The mechanism of action at the cellular level is not precisely known but is thought to be related to a mechanical effect on cell micromotion/deformation, causing an increase in stimulation of transmembrane cell adhesion molecules and upregulation of cyclooxygenase-2. Regulatory Status The Sonic Accelerated Fracture Healing System, SAFHS (also referred to as Exogen 2000 ) was initially cleared for marketing by FDA in October 1994 as a treatment of fresh, closed, posteriorly displaced distal radius (Colles) fractures and fresh, closed, or grade I open tibial diaphysis fractures in skeletally mature individuals when these fractures are orthopedically managed by closed reduction and cast immobilization. In February 2000, the labeled indication was expanded to include the treatment of established nonunions, excluding skull and vertebra. FDA product code: LPQ. Related Protocols Electrical Bone Growth Stimulation of the Appendicular Skeleton Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures Services that are the subject of a clinical trial do not meet our Technology Assessment Protocol criteria and are considered investigational. For explanation of experimental and investigational, please refer to the Technology Assessment Protocol. It is expected that only appropriate and medically necessary services will be rendered. We reserve the right to conduct prepayment and postpayment reviews to assess the medical appropriateness of the above-referenced procedures. Some of this Protocol may not pertain to the patients you provide care to, as it may relate to products that are not available in your geographic area. References We are not responsible for the continuing viability of web site addresses that may be listed in any references below. 1. Heckman JD, Ryaby JP, McCabe J, et al. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg Am. Jan 1994; 76(1): PMID Kristiansen TK, Ryaby JP, McCabe J, et al. Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. Jul 1997; 79(7): PMID Page 4 of 6

5 3. Emami A, Petren-Mallmin M, Larsson S. No effect of low-intensity ultrasound on healing time of intramedullary fixed tibial fractures. J Orthop Trauma. May 1999; 13(4): PMID Lubbert PH, van der Rijt RH, Hoorntje LE, et al. Low-intensity pulsed ultrasound (LIPUS) in fresh clavicle fractures: a multi-centre double blind randomised controlled trial. Injury. Dec 2008; 39(12): PMID Mayr E, Rudzki MM, Rudzki M, et al. [Does low intensity, pulsed ultrasound speed healing of scaphoid fractures?]. Handchir Mikrochir Plast Chir. Mar 2000; 32(2): PMID Bhandari M, Fong K, Sprague S, et al. 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 ; 94(15):e PMID Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Ultrasound accelerated fracture healing. TEC Assessments 1995; Volume 10, Tab Busse JW, Bhandari M, Kulkarni AV, et al. The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis. CMAJ. Feb ; 166(4): PMID Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ. 2009; 338:b351. PMID Griffin XL, Smith N, Parsons N, et al. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev. 2012; 2:CD PMID Griffin XL, Parsons N, Costa ML, et al. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev. 2014; 6:CD PMID Leung KS, Lee WS, Tsui HF, et al. Complex tibial fracture outcomes following treatment with low-intensity pulsed ultrasound. Ultrasound Med Biol. Mar 2004; 30(3): PMID Dijkman BG, Busse JW, Walter SD, et al. The impact of clinical data on the evaluation of tibial fracture healing. Trials. 2011; 12:237. PMID Summary of Safety and Effectiveness Data. Exogen 2000 or Sonic Accelerated Fracture Healing System (SAFHS ) Exogen, a Smith and Nephew Company, Piscataway, NJ. 15. Rutten S, Nolte PA, Guit GL, et al. Use of low-intensity pulsed ultrasound for posttraumatic nonunions of the tibia: a review of patients treated in the Netherlands. J Trauma. Apr 2007; 62(4): PMID Schofer MD, Block JE, Aigner J, et al. Improved healing response in delayed unions of the tibia with lowintensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskelet Disord. 2010; 11:229. PMID Rue JP, Armstrong DW, 3rd, Frassica FJ, et al. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. Nov 2004; 27(11): PMID Urita A, Iwasaki N, Kondo M, et al. Effect of low-intensity pulsed ultrasound on bone healing at osteotomy sites after forearm bone shortening. J Hand Surg Am. Mar 2013; 38(3): PMID Dudda M, Hauser J, Muhr G, et al. Low-intensity pulsed ultrasound as a useful adjuvant during distraction osteogenesis: a prospective, randomized controlled trial. J Trauma. Nov 2011; 71(5): PMID Salem KH, Schmelz A. Low-intensity pulsed ultrasound shortens the treatment time in tibial distraction osteogenesis. Int Orthop. Jul 2014; 38(7): PMID Page 5 of 6

6 21. National Institute for Health and Care Excellence. NICE medical technology guidance 12: EXOGEN ultrasound bone healing system for long bone fractures with non-union or delayed healing. 2013; Accessed November, American Academy of Orthopaedic Surgeons. The treatment of distal radius fractures. 2009; Accessed November, Centers for Medicare and Medicaid Services. National Coverage Decision for Osteogenic Stimulators (150.2) 2005; %3A Osteogenic+Stimulators. Accessed November, Page 6 of 6