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

This document addresses the use of neuromuscular stimulation (also known as neuromuscular electrical stimulation or NMES), which is the application of electrical stimulation for the treatment of muscular atrophy when the nerve supply to the muscle is intact. This document does not address functional electrical stimulation (FES) or transcutaneous or percutaneous electrical nerve stimulation (TENS, PENS). NMES differs from TENS, PENS and FES, in that NMES stimulation is directed to the motor nerves, while TENS/PENS is directed to the sensory nerves and FES is for use in neurologically impaired individuals.

Note: Please see the following related document(s) for additional information:

• DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
• CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous

Clinical Indications

Medically Necessary:

Neuromuscular stimulator devices are considered medically necessary when prescribed for any of the following indications when muscular atrophy is present in the setting of an intact nerve supply to the muscle, including brain, spinal cord and peripheral nerves:

1. As a component of post-operative rehabilitation in either of the following settings:
   1. When muscular atrophy is present before an orthopedic intervention (for example, repair of anterior cruciate ligament). In this setting, neuromuscular stimulation may be initiated immediately in the post-operative phase as an adjunct to physical therapy; or
   2. When muscular atrophy develops in the post-operative period. Individuals meeting this criterion typically are participating in a physical therapy program, but have experienced complications related to the surgery, which preclude successful physical therapy. In this setting, neuromuscular stimulation may be initiated only after the development of muscle atrophy; or
2. As a treatment of muscular atrophy related to other medical conditions, such as disuse atrophy; or
3. A neuromuscular stimulator garment is considered medically necessary when any of the following criteria are met:
   1. There is a large area or many sites to be stimulated and use of conventional electrodes, adhesive tapes and lead wires is not feasible; or
   2. The areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
   3. There is a documented medical condition, such as skin problems, that preclude the application of conventional electrodes, adhesive tapes and lead wires.

Not Medically Necessary: 

Neuromuscular stimulation is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to:

1. Prevention of muscle atrophy (for example, following an orthopedic procedure);
2. Treatment of pain for various musculoskeletal conditions, including, but not limited to patellofemoral syndrome, spinal stenosis, lumbago, muscle strains/sprains;
3. As a technique to increase circulation;
4. Devices with additional features, which are non-standard and are primarily for the comfort or convenience of the individual (for example, e-vive^™).