Pro Osteon Porous Hydroxyapatite Bone Graft SubstituteĪetna considers the Pro Osteon Porous Hydroxyapatite Bone Graft Substitute experimental and investigational for repair of metaphyseal fracture defects or repair of long bone cyst and tumor defects, because it has not been shown to be more effective than autograft or cadaveric allograft for these indications.Īetna considers the Pro Osteon Bone Graft Substitute experimental and investigational for use in spinal fusion, epiphyseal fractures or other indications because its effectiveness for these indications has not been established.Īetna considers the use of platelet-rich plasma, alone or in conjunction with bone grafting materials, experimental and investigational for augmentation procedures (e.g., for dental implants and for the floor of the maxillary sinus) or indications (e.g., soft tissue injuries) other than thrombocytopenia because its effectiveness has not been established.Note: The INFUSE Bone Graft is also known as bone morphogenic, or morphogenetic protein-2, BMP-2. The INFUSE Bone Graft is considered medically necessary for treating skeletally mature persons with acute, open tibial shaft fractures that have been stabilized with intramedullary nail fixation after appropriate wound management, when INFUSE Bone Graft is applied within 14 days after the initial fracture.Īetna considers the INFUSE Bone Graft experimental and investigational for all other indications, including its use in ankle fusions and cervical fusions, because its effectiveness for indications other than the ones listed above has not been established.
INFUSE Bone Graft and device is to be implanted via an anterior (ALIF) or lateral (OLIF, DLIF, XLIF or LLIF) approach.INFUSE Bone Graft is to be used with a cage (for example, the MedtronicTitanium Threaded Interbody Fusion Device, the LT-CAGE Lumbar Tapered Fusion Device, or the INTER FIX or INTER FIX RP Threaded Fusion Device) and.The member meets medical necessity criteria for lumbar spinal fusion in CPB 0743 - Spinal Surgery: Laminectomy and Fusion and.INFUSE Bone Graft (Bone Morphogenic Protein-2)Īetna considers the INFUSE Bone Graft medically necessary for lumbar spinal fusion procedures in skeletally mature persons who meet the following criteria:.Number: 0411 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
0 kommentar(er)
