CurrentColorado Rocky Mountain Health PlansPolicy CS036.Y

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Community Plan Medical Policy

Policy on coverage and medical necessity criteria for various electrical stimulation modalities (TENS, FES, NMES, and others) for treatment of pain and muscle rehabilitation for Colorado Rocky Mountain Health Plans Community Plan. Includes proven/medically necessary indications, unproven/not medically necessary indications, applicable codes, device examples, and clinical background/evidence summaries (part 1 of 10).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Community Plan Medical Policy

Policy CodePolicy CS036.Y

Change TypeRevised documentation and applicable code updates

Effective DateMay 1, 2026

Next Review Date

Key ActionProvider must document all required FES criteria (clinical findings, treatment plan, transfer and standing tolerance, prior surgeries, and absence of contraindicating conditions) to substantiate medical necessity.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary indications; replaced 'pulsed electrical stimulation (PES)' with 'pulsed electromagnetic field stimulation (PEMF) [also known as pulsed electrical stimulation (PES)]'.

Updated Medical Records Documentation Used for Reviews for Functional Neuromuscular Stimulation (FES) — added 'physician treatment plan' and revised several historical and functional items.

NMES documentation: added specific device/request purpose and comorbidities; removed 'current prescription from physician'; revised diagnostic and exam documentation wording.

TENS documentation: added condition requiring treatment, specific device/request purpose, physician treatment plan, and replacement documentation requirements.

Added CPT code 64567 to Applicable Codes.

Removed CPT code 0720T from Applicable Codes.

Supporting Information sections (Description of Services, Clinical Evidence, FDA, References) updated to reflect current information.

3Proven/Medically Necessary Modalities

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11Unproven/Not Medically Necessary Modalities

low-to-moderateOverall evidence quality

1InterQual referenced for TENS

2CPT code changes (added/removed)

Coverage Summary

Scope: Policy addresses coverage and medical necessity criteria for a range of electrical stimulation modalities for pain and muscle rehabilitation, including TENS, FES, NMES, and multiple percutaneous, implantable, and electromagnetic stimulation approaches. Coverage stance: mixed — some modalities/indications are listed as proven/medically necessary while many others are deemed unproven/not medically necessary. Status: CURRENT. Effective date: 2026-05-01.

Proven / medically necessary: TENS per InterQual criteria (see policy), FES for lower‑limb ambulation rehabilitation after spinal cord injury when ALL specific FES criteria are met (intact lower motor units L1 and below; muscle/joint stability for weight bearing; brisk contraction; sufficient sensation; motivation/cognition; independent transfers; standing tolerance ≥ 3 minutes; hand function; ≥ 6 months post recovery/restorative surgery; absence of hip/knee degenerative disease; no long‑bone fracture from osteoporosis), and NMES for defined indications (disuse atrophy with intact nerve supply, as part of comprehensive rehab after total knee arthroplasty, and to improve upper extremity function after stroke as part of comprehensive rehabilitation).

Unproven / not medically necessary (listed): Interferential therapy (IFT), Microcurrent Electrical Nerve Stimulation (MENS), Percutaneous Electrical Nerve Stimulation (PENS/PNT), Percutaneous Electrical Nerve Field Stimulation (PENFS), Percutaneous Peripheral Nerve Stimulation (PNS), Peripheral Nerve Field/Subcutaneous Field Stimulation (PNFS/PSFS), Pulsed Electromagnetic Field Stimulation (PEMF, also referenced as PES), Restorative neurostimulation, Scrambler therapy, Translingual stimulation (policy enumerates these as unproven/not medically necessary for indications not specifically supported).

Quick thresholds & responder criteria

Independent standing tolerance>= 3 minutes

Post-recovery from SCI / restorative surgery>= 6 months

Responder definition (trial threshold)>= 50% reduction in pain (VAS/NRS)

Restorative neurostimulation trial - ODI inclusion rangeODI 30 to 60

Restorative neurostimulation trial - pain NRS inclusion rangeNRS 6 to 9

Medical-Necessity Criteria

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS coverage determined by InterQual criteria referenced by policy.

> All: Refer to InterQual® CP: Durable Medical Equipment, Transcutaneous Electrical Nerve Stimulation (TENS) for medical necessity criteria. Note: InterQual CP used as the operational criteria set for TENS coverage.

Functional Electrical Stimulation (FES) - Ambulation rehabilitation for lower limb paralysis due to spinal cord injury

FES coverage for ambulation rehabilitation in lower limb paralysis due to spinal cord injury is medically necessary when ALL criteria below are met:

Demonstration of intact lower motor units (L1 and below) (both muscle and peripheral nerves).

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.

Evidence Summaries & Conclusions

Background: Electrical stimulation devices deliver direct, alternating, pulsating, and/or pulsed waveforms via surface, transcutaneous, percutaneous, or implanted electrodes to exercise muscles, evoke muscular responses, modulate pain, treat incontinence, or augment rehabilitation. Device controls typically set pulse length, frequency, amplitude, and triggering modes; electrodes may be surface, indwelling, transcutaneous, or implanted.

Common modality definitions / device functions: Functional Electrical Stimulation (FES) — coordinated application of current to intact motor neurons to produce purposeful contractions and enable functions such as standing, ambulation, grasping, respiration, or bowel/bladder voiding (surface or implanted electrodes); Neuromuscular Electrical Stimulation (NMES) — transcutaneous currents to cause muscle contractions to promote reinnervation, prevent disuse atrophy, reduce spasms, and promote voluntary control; Transcutaneous Electrical Nerve Stimulation (TENS) — surface stimulation to decrease pain perception by activating peripheral nerves and/or stimulating endorphin release; Interferential Therapy (IFT) — two medium‑frequency pulsed currents producing a low‑frequency crisscross current for deeper penetration; Microcurrent (MENS/MCT/MET/FSM) — subsensorial microampere currents intended for pain relief and wound healing; PENS — needle‑based percutaneous stimulation; PENFS — auricular/auricular field stimulation targeting vagal/auricular branches; PNS / PNFS — electrodes placed near peripheral nerves or subcutaneous field to disrupt pain signaling; PEMF (PES) — pulsed electromagnetic fields hypothesized to affect bone and cartilage healing and inflammation; Restorative neurostimulation — implanted multifidus-targeting stimulators (e.g., ReActiv8) intended to restore muscle control in chronic low back pain; Scrambler therapy — transdermal device delivering variable waveforms to present ‘nonpain’ information; and Translingual stimulation (PoNS/TLS) — neuromuscular tongue stimulation combined with therapy to promote neuroplasticity for gait/balance.

Evidence summaries and implied coverage implications: Coverage determinations are modality‑ and indication‑specific and depend on the strength and consistency of available evidence and guideline positions. TENS coverage follows InterQual criteria; FES and NMES have proven, indication‑specific roles supported by systematic reviews and HTAs for selected uses (FES for SCI ambulation under strict criteria; NMES for disuse atrophy with intact innervation and as adjunctive rehab for knee arthroplasty and some poststroke indications).

Provider Actions & Documentation Requirements

Documentation Required

Document clinical criteria for FES ambulation program

Document the specific clinical criteria when requesting authorization for a Functional Electrical Stimulation (FES) ambulation program; include objective findings and program goals to support coverage.

Intact lower motor units at L1 and below (muscle and peripheral nerves)
Independent transfer ability
Independent standing tolerance ≥ 3 minutes
Brisk muscle contraction demonstrated
Sufficient sensory perception to permit muscle contraction
Muscle and joint stability for weight bearing with balance and control to maintain upright posture independently
Hand and finger function sufficient to manipulate device controls
High level of motivation, commitment, and cognitive ability for device use
At least 6 months post-recovery from spinal cord injury and restorative surgery
Absence of hip or knee degenerative disease
No history of long-bone fracture secondary to osteoporosis

Coding

Covered / referenced HCPCS/CPT codes for electrical stimulation devices and procedures (reference list; inclusion does not guarantee coverage)mixed

0278T	Transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes).
0783T	Transcutaneous auricular neurostimulation, set-up, calibration, and patient education on use of equipment.
63650	Percutaneous implantation of neurostimulator electrode array, epidural.
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
63663	Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed.
63664	Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed.
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
64567	Percutaneous electrical nerve field stimulation, cranial nerves, without implantation.
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array.

1–10 of 41

1/5

HCPCS E0770 - Verified FES devices (PDAC verified for reporting with E0770)HCPCS

E0770*

E0770 - PDAC-verified devices include Deluxe Digital Electronic Muscle Stimulator (Drive Medical); NESS L300 and H200 devices (Bioness); Odstock ODFS Pace FES System (Odstock Medical/Boston Brace); WalkAide (Innovative Neurotronics).

FDA product codes and device categories referencedmixed

GZI	Functional electrical stimulation (FDA product code)
IPF	Neuromuscular electrical stimulation for muscle rehabilitation (FDA product code)
LIH	Interferential therapy devices (FDA product code)
ILX	Pulsed electromagnetic field stimulation devices (FDA product code)
NHI	Percutaneous/peripheral nerve stimulation (FDA product code)
GZB	Percutaneous/peripheral nerve stimulation (FDA product code)
GZF	Percutaneous/peripheral nerve stimulation (FDA product code)
LGW	Spinal cord stimulation implantable pulse generators (product code for PMA search)
GZJ	TENS / microcurrent electrical nerve stimulation (FDA product code)
NUH	TENS product code

1–10 of 15

1/2

Added CPT codesCPT

64567

CPT code added to Applicable Codes list

Removed CPT codesCPT

0720T

CPT code removed from Applicable Codes list

Definitions

Definitions / glossary:

Functional Electrical Stimulation (FES) — Direct application of electric current to intact nerve fibers to cause purposeful contractions to enable or enhance functions such as standing, ambulation, or grasping.

Neuromuscular Electrical Stimulation (NMES) — Transcutaneous application of electrical currents to cause muscle contractions to promote reinnervation, prevent disuse atrophy, relax spasms, and promote voluntary muscle control.

Transcutaneous Electrical Nerve Stimulation (TENS) — Therapeutic surface electrical stimulation to decrease pain perception by activating peripheral nerves and/or stimulating endorphin release.

Interferential Therapy (IFT) — Transcutaneous stimulation using two medium‑frequency currents that cross to produce a low‑frequency effect for deeper penetration.

Microcurrent Electrical Nerve Stimulation (MENS/MCT/MET/FSM) — Very low amplitude microampere current modalities intended for pain relief and tissue effects.

Percutaneous Electrical Nerve Stimulation (PENS) — Needle‑based percutaneous stimulation often used for short‑term pain relief and rehabilitation adjuncts.

Percutaneous Electrical Nerve Field Stimulation (PENFS) — Percutaneous auricular/auricular field stimulation targeting ear branch nerves for visceral/abdominal pain modulation.

Percutaneous Peripheral Nerve Stimulation (PNS) — Temporary or implanted leads placed near peripheral nerves to modulate pain signaling.

Peripheral Nerve Field/Subcutaneous Field Stimulation (PNFS/PSFS) — Implantation of subcutaneous electrode arrays to stimulate a diffuse painful field when the target nerve(s) are not well defined.

Medicare & Guideline Determinations

Effective	Name	Note	Type
2018-2023	NICE guidance on NMES/IFT	NICE recommends further research for NMES for dysphagia; advises NMES not be offered for knee OA (2022); suggests transcutaneous NMES for oropharyngeal dysphagia only with special arrangements (2018).	other
2016	AHA/ASA stroke rehab guideline	States NMES combined with therapy may improve spasticity but insufficient evidence for improved gait or hand use.	other
2017	ACP guideline on low back pain	Evidence insufficient to determine effectiveness of IFT; recommends nonpharmacologic treatments including electrical stimulation therapies among options.	other
	CMS guidance referenced indirectly	CMS guidance is referenced indirectly in the policy (see CMS FES coverage and HCPCS coding).	other
2019-09-05	Functional Electrical Stimulation (FES) - Coverage and HCPCS Coding - Revised	CMS: Functional Electrical Stimulation (FES) coverage and HCPCS coding revised (referenced).	NCD

Revision History

2026-05-01revisedLatest

Updated Medical Records Documentation Used for Reviews for Functional Neuromuscular Stimulation (FES) — added 'physician treatment plan' and revised several historical and functional items.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Community Plan Medical Policy

Policy CodePolicy CS036.Y

Change TypeRevised documentation and applicable code updates

Effective DateMay 1, 2026

Next Review Date

SourceLink

On This Page

Demonstration of brisk muscle contraction.

Demonstration of sensory perception sufficient for muscle contraction.

Demonstration of a high level of motivation, commitment, and cognitive ability for device use.

Ability to transfer independently.

Demonstration of independent standing tolerance for at least 3 minutes.

Demonstration of hand and finger function to manipulate controls.

Post-recovery from spinal cord injury and restorative surgery of at least 6 months.

Absence of hip and knee degenerative disease.

Absence of history of long bone fracture secondary to osteoporosis.

FES - Other indications

FES for indications other than SCI ambulation rehabilitation is considered unproven and not medically necessary.

All: FES is unproven and not medically necessary for indications other than ambulation rehabilitation for lower limb paralysis due to spinal cord injury due to insufficient evidence of efficacy.

Neuromuscular Electrical Stimulation (NMES)

NMES is medically necessary when meeting the branching criteria below. Use as part of comprehensive rehabilitation where indicated.

ONE of

Disuse muscle atrophy
- The nerve supply to the muscle is intact.
- The disuse muscle atrophy is not of neurological origin but results from other conditions, such as casting, splinting, or contractures.
When used as part of a comprehensive lower limb rehabilitation program following total knee arthroplasty.
To improve upper extremity function in persons with partial paralysis following stroke when used as part of a comprehensive rehabilitation program.

ALL of the following

NMES is unproven and not medically necessary for treating any condition not meeting the criteria above due to insufficient evidence of efficacy.

Unproven / Not Medically Necessary Modalities

The following modalities are considered unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Interferential therapy (IFT) for treating musculoskeletal disorders/injuries, or to facilitate healing of nonsurgical soft tissue injuries or bone fractures.
Microcurrent electrical nerve stimulation (MENS).
Percutaneous electrical nerve stimulation (PENS) or percutaneous neuromodulation therapy (PNT).
Percutaneous electrical nerve field stimulation (PENFS).
Percutaneous peripheral nerve stimulation (PNS).
Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS).
Pulsed electromagnetic field stimulation (PEMF) [also known as pulsed electrical stimulation (PES)].
Restorative neurostimulation.
Scrambler therapy.
Translingual stimulation for gait rehabilitation.

Evidence-based conclusions & Supportive/Administrative Criteria Revisions

Evidence-based conclusions and supportive/administrative criteria:

TENS, FES, NMES: Conclusions summarized above reflect available evidence reviews indicating benefit for the specified indications (TENS per InterQual guidance; FES for SCI ambulation when criteria met; NMES for disuse atrophy, TKA rehabilitation adjunct, and improving upper extremity function post-stroke).

Documentation and administrative requirements: Prior authorization and medical record documentation may be required to verify criteria are met (including clinical assessment of motor and sensory function, documentation of duration since injury/surgery, demonstration of functional abilities such as transfers and standing tolerance, and evidence of contraindications like osteoporosis-related fractures or degenerative joint disease).

Operational note: Devices must be used as part of a comprehensive rehabilitation program where specified; device-specific coding and billing must follow applicable HCPCS/CPT guidance and supplier verification (e.g., CMS PDAC verification for certain FES devices reported with E0770).

Evidence‑based conclusions for modalities (policy synthesis): FES demonstrates benefits in muscle strength, aerobic capacity, and select functional outcomes across SCI, CP, stroke, MS, and CHF populations but evidence quality is often low and heterogeneous; FES is considered medically necessary for SCI ambulation when detailed criteria are met and unproven for other indications not meeting those criteria. NMES shows benefit for disuse atrophy with intact nerve supply, postoperative rehabilitation (e.g., joint replacement, ACL), COPD, and dysphagia when used with conventional therapy; effects vary by timing, protocol, and patient population. IFT, MENS, PENS/PNT, PENFS, PNS, PNFS, PEMF (PES), restorative neurostimulation, scrambler therapy, and translingual stimulation have mixed or limited evidence: multiple guidelines (NICE, ACP, AAOS, AHA/ASA), HTAs (Hayes, ECRI, Ontario Health), and systematic reviews cited in the policy recommend against routine use or call for further research for many of these modalities or restrict use to research or specific, well‑defined circumstances. For restorative neurostimulation (ReActiv8), recent RCTs report clinically meaningful improvements versus optimized medical management but guideline/HTA reviewers note limitations (open‑label designs, industry funding) and call for additional independent studies. PENFS has favorable but preliminary evidence in pediatric IBS per ECRI and ESPGHAN/NASPGHAN guidance; PNS/PNFS evidence is promising in some RCTs and case series but remains limited by small samples and heterogeneity. Overall implication: implement indication‑specific coverage where policy lists proven criteria (TENS per InterQual, FES for SCI ambulation, NMES indications), and treat many percutaneous/implantable/electromagnetic modalities as unproven or subject to prior authorization pending stronger evidence or guideline endorsement.

Selected evidence highlights

RESTORE (ReActiv8) RCT participants203 participants

RESTORE primary outcomes (1 year) - ODI changeODI change: 19.7 vs 2.9 (between-group difference -16.8; p<0.001)

RESTORE primary outcomes (1 year) - NRS changeNRS change: 3.6 vs 0.6 (between-group difference -3.0; p<0.001)

Representative RCT - cerebral palsy (Moll 2023)n = 25 (randomized crossover trial)

Representative RCT - stroke (Matsumoto 2023)n = 203 (multicenter RCT)

Overall evidence certaintylow-to-moderate (policy summary of evidence quality and certainty)

Documentation Required

NMES request documentation

When requesting NMES devices or services, include explicit documentation of the device requested and the clinical rationale; provide objective exam and diagnostic evidence to support medical necessity.

Specific device or model requested and whether this is an initial trial, continuation of therapy, or a replacement device
Relevant comorbidities that affect muscle function or nerve integrity
Diagnosis and clinical history supporting NMES (e.g., disuse atrophy, post-TKA, post-stroke)
Relevant physician examination findings (strength, sensation, spasticity, transfer/ambulation status) and supporting imaging/diagnostic test results (e.g., nerve conduction studies, MRI)

Documentation Required

TENS request documentation

For TENS requests, document the clinical condition, intended purpose of the device, and the treating physician's plan; note if device is a replacement and rationale for replacement.

Clinical condition being treated and duration of symptoms
Device requested and intended purpose (e.g., pain control, adjunct to rehab)
Treating physician's treatment plan including prior conservative therapies and expected short-term goals
If a replacement device, documentation of device failure, loss, or rationale for replacement and date of prior device issuance
Refer to InterQual for TENS medical necessity criteria when applicable

Documentation Required

Evidence-based justification required for coverage decisions

Providers should supply evidence-based justification when requesting coverage for modalities with limited or evolving evidence; document prior conservative therapies tried and measurable short-term goals used to assess benefit.

List of prior conservative therapies and duration (e.g., PT, medications, injections, bracing)
Objective baseline measures and short-term measurable goals (e.g., pain NRS/VAS, functional distance, strength grades) to be used for assessing response
Rationale linking the requested modality to expected physiologic/functional benefit

Prior Authorization

Prior authorization likely for percutaneous and implantable modalities

Prior authorization may be required for percutaneous and implantable neuromodulation modalities. When submitting a PA, include high-quality evidence or guideline support that justifies the device for the requested indication.

Examples of modalities likely to require PA: percutaneous electrical nerve stimulation (PENS), percutaneous electrical nerve field stimulation (PENFS), percutaneous peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), implantable restorative systems (restorative neurostimulation)
Submit randomized controlled trials, peer-reviewed guideline recommendations, or strong case-series evidence to support use

Documentation Required

Responder documentation for PNFS/SCS trials

Document responder status for trials of peripheral neuromodulation (PNFS) and spinal cord stimulation (SCS). Trials should include baseline and follow-up pain scores and objective documentation of trial response.

Baseline pain score documented (NRS or VAS) prior to trial
Follow-up pain score during/after trial demonstrating trial response — trials commonly use ≥ 50% pain reduction as a responder threshold
Document other trial outcomes (functional improvement, medication reduction) as applicable

Documentation Required

Use FDA resources to identify device approvals/product codes

Use FDA resources to confirm device approval status and product codes when preparing documentation or claims; check PMA, De Novo, and 510(k) records using the product codes referenced in the policy.

Refer to the FDA product codes list in the policy (code_groups) to identify relevant PMA/De Novo/510(k) records and predicate devices

Billing Rule

Applicable code list updated

Applicable billing code list has been updated; ensure claims and orders reflect current code set.

CPT 64567 added
CPT 0720T removed

Pulsed Electromagnetic Field Stimulation (PEMF/PES) — Noninvasive electromagnetic field therapy with variable parameters proposed to affect bone, cartilage, inflammation, and pain.

Restorative Neurostimulation — Implantable neurostimulation targeting the multifidus (e.g., ReActiv8) intended to restore neuromuscular control and reduce chronic mechanical low back pain.

Scrambler Therapy — Noninvasive transdermal device (e.g., Calmare) delivering variable waveforms intended to replace pain signals with ‘nonpain’ information.

Translingual Stimulation (PoNS/TLS) — Neuromuscular tongue stimulation combined with supervised therapeutic exercise aiming to promote neuroplasticity to improve gait and balance.

2026-05-01revisedLatest

NMES documentation: added specific device/request purpose and comorbidities; removed 'current prescription from physician'; revised diagnostic and exam documentation wording.

2026-05-01revisedLatest

TENS documentation: added condition requiring treatment, specific device/request purpose, physician treatment plan, and replacement documentation requirements.

2026-05-01addedLatest

Added CPT code 64567 to Applicable Codes.

2026-05-01removedLatest

Removed CPT code 0720T from Applicable Codes.

2026-05-01revisedLatest

Supporting Information sections (Description of Services, Clinical Evidence, FDA, References) updated to reflect current information.