Sunflower Health Plan Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) Form

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 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 until physical therapy begins. II. It is the policy of health plans affiliated with Centene Corporation that functional neuromuscular stimulation is medically necessary for spinal cord injury (SCI) when all of the following criteria are met: A. Intact lower motor units (L1 and below, including both muscle and peripheral nerve); B. 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; C. Brisk muscle contraction to stimulation and sensory perception of electrical stimulation sufficient for muscle contraction; D. Transfers independently and demonstrates independent standing tolerance for at least three minutes; E. Demonstrates hand and finger function to manipulate controls; F. At least six months post recovery from spinal cord injury and restorative surgery; G. No hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; H. Highly motivated, committed, and the cognitive ability to use such devices for walking; I. Successfully completed a training program consisting of at least 32 physical therapy sessions with the device over a 3-month period; J. Demonstrates a willingness to use the device long-term; K. None of the following contraindications: 1. Cardiac pacemaker; 2. Severe scoliosis or severe osteoporosis; 3. Skin disease or cancer at area of stimulation; 4. Irreversible contracture; 5. Autonomic dysflexia. Page 1 of 6 CLINICAL POLICY Neuromuscular Electrical Stimulation (NMES) 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, 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, 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.1,5 There are two broad categories of NMES. One 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. 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 their 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 FES has been shown to strengthen muscles, improve circulation, heal tissue, slow muscle atrophy, and reduce pain and spasticity.4 The only settings where skilled therapists can provide 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 This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Page 2 of 6 CLINICAL POLICY Neuromuscular Electrical Stimulation (NMES) Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. HCPCS ®* Codes E0745 E0764 E0770 Neuromuscular stimulator, electronic shock unit Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified HCPCS codes that do not support coverage criteria HCPCS Codes E0744 Neuromuscular stimulator for scoliosis Muscle wasting and atrophy, not elsewhere classified Concussion and edema of cervical spinal, cord - ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code(s) requiring an additional character ICD 10 CM Code - M62.50 through M62.59 S14.0xxA through S14.0xxS S14.101A through S14.109S S24.101A through S24.109S S34.101A through S34.109S S34.131A through S34.139S Unspecified injury to sacral spinal cord Unspecified injury of cervical spinal cord Unspecified injury to unspecified level to lumbar spinal cord Unspecified injury at unspecified level of thoracic spinal cord Reviews, Revisions, and Approvals Original approval date 09/11. References reviewed and updated. Template update and approved 12/11. References reviewed and updated. Approved with no changes 9/12-9/14. References reviewed and updated. Approved by MPC. Coding update only. References reviewed and updated. Approved by MPC. No changes. References reviewed and updated. Approved by MPC. No changes. References reviewed and updated. Approved by MPC. No changes. References reviewed and updated. Approved by MPC. No changes. References reviewed and updated. Approved by MPC. No changes. Revision Date 09/11 Approval Date 09/11 09/15 09/15 09/16 07/17 07/18 07/19 07/20 09/16 07/17 07/18 07/19 07/20 Page 3 of 6 CLINICAL POLICY Neuromuscular Electrical Stimulation (NMES) Reviews, Revisions, and Approvals Transitioned to CNC template. Replaced “members” with “members/enrollees’ in all instances. Annual review completed. References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Integrated NMES, FES, and peroneal stimulator criteria from CP.MP.107 DME and Legacy WellCare Neuromuscular Electrical Stimulation (NMES) CP.MP.48 policy. Renamed to “Neuromuscular and Peroneal Nerve Electrical Stimulation.” Added section III and IV criteria. Added code E0744 to “HCPCS codes that do not support coverage criteria.” Specialist reviewed. Annual review. Criteria IV. verbiage updated for clarity. Background updated with no impact on criteria. References reviewed and updated. Specialist reviewed. Revision Date 12/20 Approval Date 07/21 07/21 07/22 07/22