CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Functional Neuromuscular Electrical Stimulation (NMES/FES)

Defines medical necessity criteria, covered indications and noncovered uses for neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) for BlueCHiP for Medicare and Commercial Products, and lists applicable HCPCS codes and prior authorization requirements for Medicare members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFunctional Neuromuscular Electrical Stimulation (NMES/FES)

Policy CodePolicy N/A

Change Typeclarified

Effective DateOct 1, 2015

Next Review Date

Key ActionPrior authorization is required for BlueCHiP for Medicare members and must be obtained via the online web-based tool for participating providers.

SourceLink

POLICY UPDATE CHANGES

Policy states FES for walking is covered for SCI patients meeting specified clinical and training criteria; NMES covered for disuse atrophy with intact nerve supply.

2Primary Covered Indications (FES for SCI; NMES for disuse atrophy)

>=32Required PT Sessions for FES Training

3 minRequired Independent Standing Tolerance

6 monthsMinimum Post-Injury Interval for SCI Candidates

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Coverage Summary

This policy covers Functional Electrical Stimulation (FES) for ambulation in selected spinal cord injury (SCI) patients who meet specified clinical and training criteria, and Neuromuscular Electrical Stimulation (NMES) for treatment of disuse muscle atrophy when the nerve supply to the muscle is intact. Coverage stance is mixed. Effective date: 2015-10-01; Last review: 2020-05-21.

Thresholds Summary

FES Training Sessions>= 32 physical therapy sessions over 3 months

Independent standing tolerance>= 3 minutes

Post-injury interval for SCI>= 6 months post recovery

Medical-Necessity Criteria

FES for Walking - BlueCHiP for Medicare Spinal Cord Injury

FES for walking is covered in SCI patients when ALL of the criteria listed below are met:

ALL of the following

Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve)
Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently
Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation sufficient for muscle contraction
Persons that possess high motivation, commitment, and cognitive ability to use such devices for walking
Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes>= 3 minutes

NMES for Muscle Atrophy (BlueCHiP for Medicare and Commercial where applicable)

NMES for treatment of muscle atrophy is covered when ONE of the criteria below is met (limited to disuse atrophy where nerve supply to the muscle is intact):

ONE of

Disuse atrophy where nerve supply to the muscle is intact (including intact brain, spinal cord and peripheral nerves)
Other non-neurological reasons for disuse atrophy (examples: casting or splinting of a limb, contracture due to scarring of soft tissue such as burn lesions, and hip replacement surgery until orthotic training begins)

FES Training Requirement

FES for SCI walking candidates must complete a documented training program:

ALL of the following

Completed a training program consisting of at least 32 physical therapy sessions with the device over a period of three months>= 32 sessions; 3 months
Physical therapy must be one-on-one and directly performed by a physical therapist
Therapy must be delivered in permitted settings: inpatient hospital, outpatient hospital, comprehensive outpatient rehabilitation facility, or outpatient rehabilitation facility
Purpose of the physical therapy trial must be to train SCI patients on the use of FES devices to achieve walking (not to reverse or retard muscle atrophy)

Not Medically Necessary / Not Covered

NMES/FES is not covered for other indications where evidence is insufficient:

ANY of the following

As a technique to restore function following nerve damage or nerve injury
As a technique to provide ambulation in patients with spinal cord injury (Commercial products)
To provide ambulation in patients with footdrop caused by congenital disorders (e.g., cerebral palsy)
To provide ambulation in patients with footdrop caused by nerve damage post-stroke

Coding

Covered HCPCS (BlueCHiP for Medicare only when medical criteria met)HCPCSCovered

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

HCPCS Listed (not medically necessary for Commercial products)HCPCSCovered

E0770

Functional electrical stimulator; transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified

Provider Actions

Prior Authorization

Prior Authorization for BlueCHiP for Medicare

Prior authorization is required for BlueCHiP for Medicare members and must be obtained via the online web-based tool for participating providers.

Documentation Required

Document training and clinical criteria

Providers must document completion of the required FES physical therapy training (>=32 sessions over 3 months), evidence of criteria listed for SCI ambulation candidates, and justification of NMES use for disuse atrophy with intact nerve supply.

Completion of at least 32 physical therapy sessions with the device over a period of three months
Evidence that the patient meets the SCI ambulation candidate criteria (intact lower motor units, ability to bear weight, independent transfers, ≥3 minutes independent standing tolerance, hand function to manipulate controls, absence of hip/knee degenerative disease, ≥6 months post recovery SCI, motivation/commitment)
Justification that NMES is being used for disuse atrophy where nerve supply to the muscle is intact (including brain, spinal cord, and peripheral nerves) or for non-neurological causes of disuse atrophy (e.g., casting, splinting, contracture from scarring, hip replacement until orthotic training)

Background & Definitions

Background: NMES delivers electrical impulses to selected muscle groups to treat muscle atrophy, whereas FES activates paralyzed or weak muscles in sequence to produce functional movements such as walking. Evidence for many functional restoration indications is limited; CMS and the policy therefore restrict NMES coverage to disuse atrophy with intact nerve supply and limit FES ambulation coverage to SCI patients who meet strict clinical criteria and complete a documented training program of at least 32 physical therapy sessions over three months.

Definitions

Evidence, Coverage Notes & CMS Alignment

Revision History

2015-10-01effective

Policy effective date established for Functional Neuromuscular Electrical Stimulation (NMES/FES).

2020-05-21last_reviewLatest

Policy last updated; documentation notes FES for walking is covered for spinal cord injury (SCI) patients meeting specified clinical and training criteria and NMES is covered for treatment of disuse muscle atrophy when nerve supply to the muscle is intact.

2020-07