CurrentBlue Cross Blue Shield - MassachusettsPolicy 321

Threshold Electrical Stimulation Policy

Policy governs coverage and prior authorization requirements for threshold electrical stimulation as a treatment for motor disorders (including cerebral palsy) for commercial members of Blue Cross Blue Shield Massachusetts. It states coverage stance and billing/authorization notes for inpatient and outpatient settings.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyThreshold Electrical Stimulation Policy

Policy CodePolicy 321

Change TypeAnnual review; historical edits

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for inpatient services described in this policy; check member contract benefits to determine coverage.

SourceLink

POLICY UPDATE CHANGES

Annual policy review updated literature through September 2022; policy statements unchanged.

Medicare information removed referencing MP #132.

New policy describing ongoing non-coverage for threshold electrical stimulation effective 5/1/2011.

1Coverage stance: Not medically necessary

CommercialApplies to

Inpatient preauth requiredPrior Authorization

Coverage Summary

Policy governs coverage and prior authorization requirements for threshold electrical stimulation (TES) as a treatment for motor disorders (including cerebral palsy) for Commercial members of Blue Cross Blue Shield Massachusetts. Coverage stance: Not medically necessary / Not covered (cosmetic). Applies to: Commercial. Inpatient services require precertification/preauthorization; outpatient coverage varies by product.

Policy metadata

Policy Number321

SubjectThreshold electrical stimulation

StatusCURRENT (Not medically necessary for treatment of motor disorders)

Last review2022-09

Effective date5/1/2011 (policy established)

Medical Necessity / Coverage Criteria

Medically Necessary Determination

Threshold electrical stimulation is considered not medically necessary for treatment of motor disorders when used for the indications below:

Treatment description: Treatment is threshold electrical stimulation (delivery of low-intensity electrical stimulation to target spastic muscles that is not intended to cause muscle contraction)
Indications: Indication includes treatment of spasticity, muscle weakness, reduced joint mobility, or impaired motor function (including but not limited to cerebral palsy, spina bifida, spinal muscular atrophy)
Use setting: outpatient or home use (including use during sleep) or following selective posterior rhizotomy

Summary of literature: Available randomized controlled trials and other studies demonstrate that TES is not effective for treatment of spasticity, muscle weakness, reduced joint mobility, or motor function.

Key references: Multiple RCTs and reviews are cited as examples, including Dali et al. (2002), Steinbok et al. (1997), van der Linden et al. (2003), and Kerr et al. (2006).

Not Medically Necessary / Not Covered

Threshold electrical stimulation is considered not medically necessary / not covered for treatment of motor disorders (including cerebral palsy) as described in this policy. The policy was established as a non-coverage policy effective 5/1/2011, and the non-coverage determination remained unchanged on the most recent annual review (policy statements unchanged as of the September 2022 review).

Medically Necessary Determination

Threshold electrical stimulation is considered not medically necessary for treatment of motor disorders when used for the indications below:

Not Covered Determination (Duplicate of Medically Necessary Determination to indicate Not Medically Necessary status)

Treatment description: Treatment is threshold electrical stimulation (delivery of low-intensity electrical stimulation to target spastic muscles that is not intended to cause muscle contraction)
Indications: Indication includes treatment of spasticity, muscle weakness, reduced joint mobility, or impaired motor function (including but not limited to cerebral palsy, spina bifida, spinal muscular atrophy)
Use setting: outpatient or home use (including use during sleep) or following selective posterior rhizotomy

Coding

CPT CodesCPT

There is no specific CPT code for this service

Policy Identifiersmixed

321	Policy Number (internal header)
1.01.19A	BCBSA Reference Number (for plan internal use only)

Absence of a specific CPT code does not imply coverage; providers should report services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Provider Action Items

Prior Authorization

Precertification/Preauthorization required for inpatient services

Precertification/preauthorization is required for services described in this policy if the procedure is performed inpatient for all products.

Documentation Required

Check member contract benefits

Inclusion or exclusion of a code does not imply member coverage; providers must refer to the member's contract benefits in effect at time of service to determine coverage.

Billing Rule

Reporting codes

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

Background and Definitions

Threshold electrical stimulation (TES) delivers low-intensity electrical stimulation to spastic muscles via a generator, lead wires, and surface electrodes and is not intended to cause muscle contraction. The technique has been used most extensively in children with spastic diplegia related to cerebral palsy and in other motor disorders such as spina bifida.

Threshold electrical stimulation: Delivery of low-intensity electrical stimulation to target spastic muscles not intended to cause muscle contraction; provided by a generator, leads, and surface electrodes placed over targeted muscles.

Revision History

2011-05-01added

New policy describing ongoing non-coverage for threshold electrical stimulation effective 5/1/2011. Policy established non-coverage based on available evidence.

2021-01revised

Medicare information removed referencing MP #132; no change to policy statements.

2022-09revisedLatest