Clinical Policy: Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

Reference Number: CP.MP.48
Date of Last Revision: 06/24

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

This policy describes the medical necessity requirements for the use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES).

Policy/Criteria

I. It is the policy of health plans affiliated with Centene Corporation® that neuromuscular electrical stimulation (NMES) is medically necessary when used as one component of a comprehensive rehab program for the treatment of disuse atrophy when the nerve supply to the atrophied muscle is intact and has any of the following atrophy indications:
A. Contractures due to burn scarring;
B. Previous casting or splinting of a limb;
C. Major knee surgery with failure to respond to physical therapy;
D. Recent hip replacement and NMES will be used until physical therapy begins.

II. It is the policy of health plans affiliated with Centene Corporation that functional electrical stimulation (FES) is medically necessary for spinal cord injury (SCI) when all of the following criteria are met:
A. The member/enrollee has brisk muscle contraction to stimulation and sensory perception of electrical stimulation sufficient for muscle contraction;
B. At least six months have passed since recovery from spinal cord injury and restorative surgery;
C. Member/enrollee is highly motivated, committed, and has the cognitive ability to use FES devices for walking;
D. Successful completion of a training program consisting of at least 32 physical therapy sessions with the device over a three-month period;
E. Member/enrollee demonstrates a willingness to use the device long-term;
F. None of the following contraindications are present:

  1. Cardiac pacemaker;  
  2. Severe scoliosis or severe osteoporosis;  
  3. Skin disease or cancer at area of stimulation;  
  4. Irreversible contracture;  
  5. Autonomic dysreflexia;

G. If lower extremity FES is requested, all of the following:

  1. Intact lower motor units (L1 and below, including both muscle and peripheral nerve);  
  2. Muscle and joint stability adequate for weight bearing at upper and lower extremities and can demonstrate balance and control to maintain an upright support posture independently;  
  3. Transfers independently and demonstrates independent standing tolerance for at least three minutes;

CLINICAL POLICY

Neuromuscular Electrical Stimulation (NMES)

4. Demonstrates hand and finger function to manipulate controls;
5. No hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis.

III. It is the policy of health plans affiliated with Centene Corporation that peroneal nerve stimulators (e.g., NESS L300, NESS L300 Plus, L300 Go System, WalkAide, Odstock [ODFS®] Dropped Foot Stimulator) are medically necessary for incomplete spinal cord injury.

IV. It is the policy of health plans affiliated with Centene Corporation that peroneal nerve stimulators (e.g., NESS L300, NESS L300 Plus, L300 Go System, WalkAide, Odstock [ODFS®] Dropped Foot Stimulator) have not been proven safe and effective for any indication other than incomplete spinal cord injury, including, but not limited to: foot drop in cerebral palsy, multiple sclerosis, traumatic brain injury, or stroke.

V. It is the policy of health plans affiliated with Centene Corporation that neuromuscular electrical stimulation for any other indication (e.g., idiopathic scoliosis, heart failure) is not proven safe and effective.

Background

Neuromuscular electrical stimulation (NMES) involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.¹,² There are two broad categories of NMES. The first type of device stimulates the muscle when the patient is in a resting state to treat muscle atrophy.¹ The second type, known as functional electrical stimulation (FES), is used to enhance functional activity of neurologically impaired patients.¹

NMES can be performed at low, medium, or high intensity to elicit mild, moderate, or strong muscle contractions. NMES can be performed on upper or lower limbs. When used at very low intensity to stimulate barely perceptible contractions, this technique is referred to as threshold NMES or threshold electrical stimulation (TES).¹,⁴ Regardless of the intensity of NMES, patients are encouraged to exercise the affected muscles voluntarily to maintain and improve strength and function. For chronic disorders, this exercise may be in the form of regular participation in sports activities. For acute conditions, such as rehabilitation shortly after surgery or a stroke, patients must often undergo intensive physical and occupational therapy.¹,⁴

FES is the application of electrical stimulation that can be used to activate muscles of the upper or lower limbs to produce functional movement patterns, such as standing and walking in patients with paraplegia.¹,⁴ Although FES is used to treat the effects of upper motor neuron lesions, it is not normally suitable for patients with lower motor neuron lesions.¹⁰

FES can also be used therapeutically for cycling of the upper and/or lower limbs, with the goal of strengthening to produce functional movement patterns.⁹

FES has been shown to strengthen muscles, improve circulation, heal tissue, slow muscle atrophy, and reduce pain and spasticity.⁴

CLINICAL POLICY

Neuromuscular Electrical Stimulation (NMES)

There is evidence from preliminary studies that FES can improve gait in some patients; however, additional larger randomized trials are needed.³,²,⁶

The only settings where skilled therapists can provide both types of NMES services are inpatient hospitals, outpatient hospitals, comprehensive outpatient rehabilitation facilities, and outpatient rehabilitation facilities. The physical therapy needed to perform these services requires that the patient be in a one-on-one training program.¹

Coding Implications