ModifiedColorado Rocky Mountain Health PlansPolicy MMP090.17

Electrical Stimulators

Medicare Advantage policy guidance for use, coverage, and coding of electrical stimulation therapies (auricular electro-acupuncture, dysphagia stimulation, occipital and peripheral nerve stimulation, PENS/PNT, implanted and percutaneous peripheral nerve stimulation, vagus nerve stimulation) as applied to UnitedHealthcare Medicare Advantage plans and related Medicare contractor determinations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyElectrical Stimulators

Policy CodePolicy MMP090.17

Change TypeRevised — coverage rationale updated

Effective DateJun 1, 2026

Next Review Date

Key ActionFollow Medicare LCD/LCA requirements where applicable and refer to the UnitedHealthcare commercial policy for guidance when Medicare guidance is absent.

SourceLink

POLICY UPDATE CHANGES

Revised language to indicate LCDs/LCAs for electrical stimulation of auricular acupuncture points have retired and no longer exist, and refer readers to the UnitedHealthcare commercial policy for coverage guidelines.

Updated list of documents available in the Medicare Coverage Database to reflect the most current information.

2026-06-01Effective

Apr 8, 2026Last approval

MMP090.16Previous

6Applies in

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Coverage Criteria and Policy Scope

No explicit coverage criteria are included in the provided source content. The following statements describe the scope, applicability, and informational disclaimers that govern coverage determinations for electrical stimulation-related therapies referenced in this policy.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service; benefit coverage is determined by the member specific benefit plan document and applicable laws.

In the absence of a Medicare National Coverage Determination (NCD) specific to a therapy, Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) — where they exist — must be followed. Where LCDs/LCAs have retired or do not exist, UnitedHealthcare commercial or internal medical policy guidance may be used to determine coverage.

UnitedHealthcare applies internal coverage criteria when Medicare source materials do not fully establish clinical coverage criteria or allow flexibility that could permit coverage beyond listed indications. These internal criteria were developed by evaluating current clinical evidence and widely used treatment guidelines.

Medicare Advantage Policy documents are informational and intended to support UnitedHealthcare coverage decisions. They do not constitute medical advice and are not exhaustive clinical guidance. Treating physicians and providers retain responsibility for clinical decision-making and should maintain documentation to support medical necessity when requested.

Benefit coverage for health services is determined by the member-specific benefit plan document; in the event of a conflict between this policy and the member-specific benefit plan, the plan document supersedes the policy.

For states/territories where LCDs/LCAs exist, compliance with those policies is required where applicable. For states/territories without applicable LCDs/LCAs or where LCDs/LCAs have retired, refer to the cited UnitedHealthcare Commercial Medical Policies for coverage guidelines (examples cited in source: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation; Occipital Nerve Injections and Ablation; Vagus and External Trigeminal Nerve Stimulation).

Providers are responsible for submission of accurate claims and for following any delegate-managed utilization management and prior authorization requirements applicable to the member's Medicare Advantage plan.

The inclusion of procedure and diagnosis codes in the policy is for reference only; it does not guarantee reimbursement or payment. Other policies and guidelines may apply.

Procedure Codes and Coding Guidance

Applicable procedure codes (reference)CPT | HCPCS

61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array.
61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays.
63650	Percutaneous implantation of neurostimulator electrode array, epidural.
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64999	Unlisted procedure, nervous system [Refer to the UnitedHealthcare Commercial Medical Policy titled Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation]
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

Coding guidance referencesmixed

No codes listed

Not applicable — coding thresholds

Not applicableThis placeholder indicates no coding thresholds apply in this section.

ContextUsed where 'Not applicable' is the authoritative entry for coding thresholds.

ActionNo codes or frequency thresholds specified in this policy excerpt.

Provider Responsibilities and Prior Authorization

Prior Authorization

Delegate-managed prior authorization

For members whose plan requires prior authorization and where a delegate manages utilization management (UM) and prior authorization (PA) requirements, providers must follow the delegate’s UM/PA processes and timelines. Verify the applicable delegate requirements before submitting authorization requests.

Delegate-managed PA requirements must be followed when applicable.
Contact the delegate or refer to the member’s plan materials for delegate-specific forms, submission portals, and timelines.

Denial Risk

Claims accuracy risk

Providers are responsible for submitting accurate, complete claims and documentation. Inaccurate, incomplete, or inconsistent claims may lead to delayed processing, denials, recoupments, or other payment issues.

Ensure coding, modifiers, dates of service, and supporting documentation match clinical records.

Conservative Treatment Preconditions

Frequency and Utilization Limits

Frequency limits — overview

Summary statementListed procedures may be subject to plan or Medicare contractor limits; no explicit frequency limits provided in this excerpt.

Provider responsibilityBenefit coverage and any frequency limits are determined by the member-specific benefit plan document and applicable Medicare contractor guidance.

Reference guidanceRefer to applicable LCDs/LCAs, NCDs, or UnitedHealthcare commercial policies for modality-specific frequency or utilization limits.

Claims submissionProviders are responsible for submission of accurate claims; absence of explicit frequency limits here does not guarantee coverage.

Frequency limits — placeholder

Frequency limits

Imaging and Diagnostic Requirements

Note

No imaging requirements specified — follow LCD/LCA or UHC policy

No specific imaging requirements are specified in this policy excerpt; when imaging is required, follow modality-specific LCDs/LCAs or UnitedHealthcare policy guidance.

Refer to applicable Local Coverage Determinations or UnitedHealthcare commercial policies for modality-specific imaging guidance.

Note

Check modality-specific imaging requirements when applicable

If imaging requirements apply for a specific modality or contractor, follow the applicable LCD/LCA or plan-specific guidance; this policy excerpt does not specify imaging prerequisites.

Check the relevant LCD/LCA or UnitedHealthcare policy for any required imaging prior to the procedure.

Background and Policy Context

This policy addresses multiple electrical stimulation modalities used for pain management and rehabilitation, including auricular electro-acupuncture, dysphagia stimulation, occipital and peripheral nerve stimulation, PENS/PNT, implanted and percutaneous peripheral nerve stimulation, and vagus nerve stimulation. Where Medicare NCDs or LCDs apply, those determinations must be followed; where they do not exist the Policy refers to UnitedHealthcare commercial policy guidance.

Definitions and Key Terms

Electrical Stimulation of Auricular Acupuncture Points — definition and alternate terms

TermElectrical Stimulation of Auricular Acupuncture Points

Also known asElectro-acupuncture stimulation; peripheral subcutaneous field stimulation (PSFS); peripheral nerve field stimulation (PNFS)

Medicare guidanceNo Medicare NCD exists specifically; LCDs/LCAs have retired and no longer exist; refer to UnitedHealthcare commercial policy for coverage guidelines.

Functional electrical stimulator — definition

DefinitionFunctional electrical stimulator: transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified.

Coding example

Not Covered / Exclusions

No procedures are explicitly listed as not covered in this excerpt. Coverage decisions depend on the applicable National Coverage Determination (NCD) or Local Coverage Determination/Article (LCD/LCA) status and the member’s specific benefit plan; providers should verify coverage through the member’s benefit document or customer service and follow any applicable Medicare contractor guidance.