Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

MP 7.01.11

Ilizarov Bone-Lengthening Procedure


Medical Policy
Section
Surgery
Original Policy Date
12/1/95
Last Review Status/Date
Reviewed by consensus/2:2004
Issue
4:2004
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

The Ilizarov bone-lengthening procedure uses a circular external fixator device that attaches to the bone via transfixion wires. A corticotomy (percutaneous osteotomy) is performed, permitting attachment of the wires. Periodic adjustment of the external fixator produces a distractive lengthening force, which gradually stimulates new bone growth.


Policy

Bone-lengthening procedures are considered medically necessary for the correction of congenital or post-traumatic limb length discrepancies and angular deformities of the limb (arm, forearm, thigh, or leg). Specific cases include:

  • demonstrable non-union or mal-union of long bone with or without bone loss or infection;
  • lengthening of an amputation stump where needed for proper fitting of a prosthesis;
  • leg lengthening needed to equalize leg length discrepancy greater than 6 cm and to correct congenital or post-traumatic angular/rotational deformations of the long bones;
  • bone defects with or without deformities.

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

Use of a bone-lengthening device for the sole purpose of altering short stature is not medically necessary.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

The Ilizarov technique is a specialized procedure that may require out of network referral.


Rationale

A literature search for the period of 1995 through July 2004 reveals that the Ilizarov procedure is an effective and accepted procedure for the correction of congenital or post-traumatic limb length discrepancies and angular deformities of the limb (arm, forearm, thigh, or leg). (1-4)

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.

 

Codes

Number

Description

CPT 

20690 

Application of uniplane, unilateral, external fixation system 

 

20692 

Application of multiplane, unilateral, external fixation system (e.g., Ilizarov, Monticelli type). List 20692 in addition to code for treatment of fracture or joint injury unless listed as part of basis procedure 

 

20693 

Adjustment or revision of external fixation system requiring anesthesia 

 

20694 

Removal, under anesthesia, of external fixation system 

ICD-9 Procedure 

78.10 

Application of external fixation devices: 

 

78.12 

Humerus 

 

78.13 

Radius 

 

78.15 

Femur 

 

78.17 

Fibula, tibia 

 

 

For bone-lengthening procedures use: 

 

78.32 

Humerus 

 

78.33 

Radius and ulna 

 

78.35 

Femur 

 

78.37 

Tibia and fibula 

 

736.09 

Other acquired deformity of forearm, excluding fingers 

 

736.81 

Unequal leg length (acquired) 

 

736.89 

Other acquired deformity (arm, leg, shoulder, neck) 

 

736.39 

Other acquired deformity (angulation) of hip 

 

755.24 

Longitudinal deficiency, humeral, complete or partial 

 

755.25 

Longitudinal deficiency, radioulnar, complete or partial 

 

755.26 

Longitudinal deficiency, radial, complete or partial 

 

755.27 

Longitudinal deficiency, ulnar, complete or partial 

 

755.34 

Longitudinal deficiency, femoral, complete or partial 

 

755.35 

Longitudinal deficiency, tibiofibular, complete or partial 

 

755.36 

Longitudinal deficiency, tibial, complete or partial 

 

755.37 

Longitudinal deficiency, fibular, complete or partial 

ICD-9 Diagnosis 

755.59 

Congenital angulation, forearm 

 

755.69 

Congenital angulation, leg 

Type of Service 

No code 

Type of Service 

 

Place of Service 

Inpatient 


Index

Bone Lengthening, Ilizarov Procedure
Ilizarov Bone Lengthening Procedure


Policy History

Date Action Reason
12/01/95 Add to Surgery section New policy
7/31/97 Replace policy Revised policy: revised ICD-9 code
4/15/02 Replace policy Policy reviewed by consensus; new review date only
7/17/03 Replace policy Policy reviewed by consensus; no changes in policy
11/9/04 Replace policy Policy reviewed with literature search; no change in policy statement; references added; no further review scheduled


Search for Policies

Policy Feedback