Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)
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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.
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).
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.
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
FES — Medically Necessary for Spinal Cord Injury (SCI)
FES is medically necessary for SCI when ALL of the following criteria are met:
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
Peroneal Nerve Stimulators — Medically Necessary Indication
Peroneal nerve stimulators are medically necessary for:
Coding
| 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. |
| E0744 | Neuromuscular stimulator for scoliosis |
Provider Actions
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
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
Medicare Determinations
| Name | Number | Effective Date | Type |
|---|---|---|---|
| Neuromuscular electrical stimulation (NMES) | 160.12 | 2006-10-01 | NCD |
Revision History
Annual review. Updated language in Criteria I.A. for clarity; coding and descriptions reviewed; references reviewed and updated; reviewed by internal specialist.
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.
Integrated NMES, FES, and peroneal stimulator criteria from legacy policies; renamed to 'Neuromuscular and Peroneal Nerve Electrical Stimulation'; added sections III and IV relating to peroneal nerve stimulators and limitations of indications; added HCPCS code E0744 to non-supporting codes.
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