321 Form

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Medical Policy Threshold Electrical Stimulation as a Treatment of Motor Disorders Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 321

BCBSA Reference Number: 1.01.19A (For Plan internal use only) Related Policies
NMES (Neuromuscular Electrical Stimulation), #201 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Threshold electrical stimulation as a treatment of motor disorders, including but not limited to cerebral palsy is NOT MEDICALLY NECESSARY.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes

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There is no specific CPT code for this service. Description Threshold electrical stimulation is described as the delivery of low-intensity electrical stimulation to target spastic muscles during sleep at home. The stimulation is provided by a small electrical generator, lead wires, and surface electrodes that are placed over the targeted muscles; it is not intended to cause muscle contraction. Although the mechanism of action is not understood, it is thought that low-intensity stimulation may increase muscle strength and joint mobility, leading to improved voluntary motor function.
The technique has been used most extensively in children with spastic diplegia related to cerebral palsy but also in those with other motor disorders, such as spina bifida. Summary The studies published to date demonstrate that threshold electrical stimulation is not effective for treatment of spasticity, muscle weakness, reduced joint mobility, or motor function; therefore, the treatment is considered not medically necessary. Policy History Date Action 9/2022 Annual policy review. Policy updated with literature review through September 2022.
No references added. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
2/2020 Policy updated with literature review through February 1, 2020, no references added. Policy statements unchanged. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
6/2011 Reviewed 6/2011 MPG – Orthopedics, Rehabilitation and Rheumatology. No changes to policy statements. 5/1/2011 New policy effective 5/1/2011 describing ongoing non-coverage. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Steinbok P, Reiner A, Kestle JR. Therapeutic electrical stimulation (ThresholdES) following selective posterior rhizotomy in children with spastic diplegic cerebral palsy: a randomized clinical trial. Dev Med Child Neurol 1997; 39(8):515-20.
2. Dali C, Hansen FJ, Pedersen SA et al. Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial. Dev Med Child Neurol 2002; 44(6):364-9.
3. van der Linden ML, Hazlewood ME, Aitchison AM et al. Electrical stimulation of gluteus maximus in children with cerebral palsy: effects on gait characteristics and muscle strength. Dev Med Child Neurol 2003; 45(6):385-90.
4. Fehlings DL, Kirsch S, McComas A et al. Evaluation of therapeutic electrical stimulation to improve muscle strength and function in children with types II/III spinal muscular atrophy. Dev Med Child Neurol 2002; 44(11):741-4.
5. Ozer K, Chesher SP, Scheker LR. Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Dev Med Child Neurol. 2006; 48(7):559-63.

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6. Kerr C, McDowell B, Cosgrove A et al. Electrical stimulation in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 2006; 48(11):870-6.
7. Lannin N, Scheinberg A, Clark K. AACPDM systematic review of the effectiveness of therapy for children with cerebral palsy after botulinum toxin A injections. Dev Med Child Neurol 2006; 48(6):533-9.
8. The National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope through research. Last updated June 13, 2011. Available online at: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#179393104 . Last accessed September 2011.
9. Bouthour W, et al. Short pulse width in subthalamic stimulation in Parkinson's disease: a randomized, double-blind study. Mov Disord 2018 - Clinical Trial. PMID 29266392
10. Diego Serrano-Muñoz et al. 20-kHz alternating current stimulation: effects on motor and somatosensory thresholds. J Neuroeng Rehabil. 2020 Feb 19;17(1):22.