CurrentArizona Complete HealthPolicy CP.MP.48

Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)

Defines medical necessity criteria for NMES, functional electrical stimulation (FES), and peroneal nerve stimulators for members of Centene-affiliated health plans, including covered indications, contraindications, and non-covered uses, with referenced HCPCS codes and coding guidance.

Policy Summary

PayerArizona Complete Health

PolicyNeuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)

Policy CodePolicy CP.MP.48

Change TypeClarifiedRevisedAdded

Effective Date

Next Review Date

Key ActionProviders must document that NMES is used as part of a comprehensive rehabilitation program for disuse atrophy and that the nerve supply to the atrophied muscle is intact, with one of the specified indications.

SourceLink

POLICY UPDATE CHANGES

Annual review updated language in Criteria I.A. for clarity and minor rewording with no clinical significance (05/25 revision).

Removed several contraindications under II.F. during 06/24 annual review.

Added section III and IV criteria relating to peroneal nerve stimulators and limitations of indications (07/21 integration).

3Primary covered modalities (NMES, FES, Peroneal stimulators)

1HCPCS codes not supporting coverage

32Min PT sessions for FES training

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Coverage Summary

Overview: This policy (CP.MP.48) defines medical necessity criteria for neuromuscular and peroneal nerve electrical stimulation, covering three primary modalities: NMES, FES, and peroneal nerve stimulators. The coverage stance is mixed: NMES and peroneal stimulators have defined medically necessary uses while many other indications are not supported. The subject is Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES/FES/Peroneal Stimulators) and the policy status is CURRENT.

Definitions: NMES — device transmits an electrical impulse to the skin over selected muscle groups to elicit contractions (includes threshold NMES/TES when very low intensity is used to stimulate barely perceptible contractions). FES — electrical stimulation used to activate muscles to enhance functional activity and produce movements such as standing and walking. These definitions distinguish NMES for treating muscle atrophy and FES for producing functional movements.

Key thresholds and quick facts

Training sessions for FES>= 32 physical therapy sessions over a 3-month period

Time since SCI>= 6 months since recovery from spinal cord injury and restorative surgery

Independent standing tolerance>= 3 minutes independent standing tolerance for lower extremity FES

Primary covered modalities3 (NMES, FES, Peroneal stimulators)

HCPCS codes not supporting coverage1 (E0744 neuromuscular stimulator for scoliosis)

Medical Necessity Criteria

NMES — Medically Necessary for Disuse Atrophy

NMES is medically necessary when used as one component of a comprehensive rehabilitation program for treatment of disuse atrophy when the nerve supply to the atrophied muscle is intact and ANY of the following are present:

ANY of the following

Contractures due to scarring of soft tissue (e.g., burn lesions)
Previous casting or splinting of a limb
Major knee surgery with failure to respond to physical therapy
Recent hip replacement and NMES will be used until physical therapy begins

Coding

HCPCS codes referenced / supporting discussionHCPCS

E0745	Neuromuscular stimulator, electronic shock unit.
E0764	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.
E0770	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 criteriaHCPCSNot Covered

E0744

Neuromuscular stimulator for scoliosis

Provider Actions

Documentation Required

Document indication and intact nerve supply for NMES

Providers must document that NMES is being used as part of a comprehensive rehabilitation program for disuse atrophy and that nerve supply to the atrophied muscle is intact, with one of the specified indications (e.g., contracture, prior casting, post-knee surgery refractory to PT, recent hip replacement until PT begins).

Contractures due to scarring of soft tissue (e.g., burn lesions)
Previous casting or splinting of a limb
Major knee surgery with failure to respond to physical therapy
Recent hip replacement and NMES will be used until physical therapy begins

Documentation Required

Document FES candidacy and training completion

For FES in SCI, document brisk muscle contraction and sensory perception to stimulation, motivation and cognitive ability, completion of at least 32 physical therapy sessions with the device over 3 months, willingness for long-term use, absence of listed contraindications, and (for LE FES) the specific motor, balance, transfer and joint stability criteria.

Background, Evidence & Definitions

Background summary: Two broad categories are described. NMES (including threshold NMES/TES) stimulates muscles while the patient is at rest primarily to treat or prevent disuse muscle atrophy and can be applied at low, medium, or high intensity to elicit varying contraction strengths. FES is applied to activate muscles to produce functional movement patterns (for example, standing and walking) in neurologically impaired patients.

Settings and provision: 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, and the physical therapy requires one-on-one training.

Evidence for gait improvement: FES has preliminary evidence from small studies that it can improve gait in some patients, but additional larger randomized trials are needed.

Source	Notes
CMS NCD referenced	Neuromuscular electrical stimulation (NMES) (160.12), published October 01, 2006
Hayes HTA	FES for foot drop in stroke (Published June 01, 2022; annual review June 14, 2024)

Definitions

NMES: device transmits electrical impulse to skin over selected muscle groups to elicit contractions.

FES: electrical stimulation used to enhance functional activity and produce movements such as standing and walking.

Medicare Determinations

Name	Number	Effective Date	Type
Neuromuscular electrical stimulation (NMES)	160.12	2006-10-01	NCD

Revision History

05/25clarified

Annual review. Updated language in Criteria I.A. for clarity; coding and descriptions reviewed; references reviewed and updated; reviewed by internal specialist.

06/24material_change_removed_contraindications

Annual review. Removed several contraindications under II.F., including uncontrolled cardiac arrhythmias, unstable angina, joint replacement in a location targeted by FES, and seizure disorder.

07/21material_change_integration_added

ALL of the following

Member/enrollee has brisk muscle contraction to stimulation and sensory perception of electrical stimulation sufficient for muscle contraction
At least six months have passed since recovery from spinal cord injury and restorative surgery>= 6 months
Member/enrollee is highly motivated, committed, and has the cognitive ability to use FES devices for walking
Successful completion of a training program consisting of at least 32 physical therapy sessions with the device over a three-month period>= 32 PT sessions over 3 months
Member/enrollee demonstrates a willingness to use the device long-term
None of the following contraindications are present
- Cardiac pacemaker
- Severe scoliosis or severe osteoporosis
- Skin disease or cancer at area of stimulation
- Irreversible contracture
- Autonomic dysreflexia
If lower extremity FES is requested, ALL of the following
- Intact lower motor units (L1 and below, including both muscle and peripheral nerve)
- 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
- Transfers independently and demonstrates independent standing tolerance for at least three minutes>= 3 minutes
- Demonstrates hand and finger function to manipulate controls
- No hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis