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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) Form

Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses uses of functional electrical stimulation (FES) and threshold electrical stimulation (TES) devices. FES is used in neurologically impaired individuals, including those with spinal cord injury and stroke, to stimulate muscles during activity. TES, also referred to as therapeutic electrical stimulation, involves the delivery of low intensity electrical stimulation (typically at night) and has been proposed as a treatment of cerebral palsy and scoliosis.

Note: For information regarding devices that may be utilized by individuals with neurological disorders affecting the ability to ambulate without assistance, please see the following document:

  • OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

Note: FES has been used to treat or prevent muscle disuse atrophy in individuals with neurologic impairment. However, the use of electrical stimulation for the same indication in individuals without neurologic injury is addressed in the following document:

  • CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Position Statement

Investigational and Not Medically Necessary:

Functional electrical stimulation (FES) is considered investigational and not medically necessary for all indications, including but not limited to:

  • When used to prevent or reverse muscular atrophy (wasting) and bone demineralization (loss), by stimulating paralyzed limbs for the performance of stationary exercise, or to correct gait disorders. This includes, but is not limited to, functional electrical stimulation ergometer devices (for example, ERGYS® and ERGYS® 2); or
  • When used to promote ambulation (for example, Parastep® I System); or
  • When used to activate muscles of the upper limb or lower limb to produce functional movement patterns. This includes, but is not limited to, the NESS H200® Handmaster Rehabilitation System, NESS L300™ Foot Drop System, ODFS Dropped Foot Stimulator, and the WalkAide® System.

Threshold electrical stimulation (TES) is considered investigational and not medically necessary for all indications including, but not limited to, treatment of motor disorders such as cerebral palsy or scoliosis.