CurrentmhnPolicy CP.MP.48

Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

Medical necessity criteria for use of neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), and peroneal nerve stimulators for members of health plans affiliated with Centene Corporation.

Policy Summary

Payermhn

PolicyNeuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

Policy CodePolicy CP.MP.48

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets the policy's medical necessity criteria, including required FES training completion when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3device/therapy sections

32FES training min sessions

6FES contraindications

3supportive HCPCS codes

1non-supportive HCPCS

Coverage Criteria for NMES, FES, and Peroneal Nerve Stimulators

NMES for disuse atrophy

Covered when ALL of the following are met

NMES 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 the member has one of the following atrophy indications: 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 when NMES will be used until physical therapy begins.

FES for spinal cord injury (SCI)

Covered when ALL of the following are met

FES SCI eligibility: Member has brisk muscle contraction to stimulation and sensory perception sufficient for contraction; at least six months have passed since recovery from spinal cord injury and restorative surgery; member is highly motivated, committed, and cognitively able to use FES for walking; successful completion of a training program consisting of at least 32 physical therapy sessions with the device over a three-month period; member demonstrates willingness to use device long-term; none of the listed contraindications are present.

Policy Summary

Payermhn

PolicyNeuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

Policy CodePolicy CP.MP.48

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets the policy's medical necessity criteria, including required FES training completion when applicable.

SourceLink

On This Page

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Contraindications listed separately.

FES lower extremity unit requirements: If lower extremity FES is requested: intact lower motor units (L1 and below, including both muscle and peripheral nerve); muscle and joint stability adequate for weight bearing with demonstrated balance and control to maintain an upright support posture independently; transfers independently and demonstrates independent standing tolerance for at least three 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

Stance

Peroneal stimulators for incomplete SCI: Peroneal nerve stimulators (examples: NESS L300, NESS L300 Plus, L300 Go, WalkAide, Odstock) are medically necessary for incomplete spinal cord injury.

Peroneal stimulators other indications: Peroneal nerve stimulators have not been proven safe and effective for any indication other than incomplete spinal cord injury, including but not limited to foot drop in cerebral palsy, multiple sclerosis, traumatic brain injury, or stroke.

NMES not proven safe/effective for other indications

Other indications: Neuromuscular electrical stimulation for any other indication (e.g., idiopathic scoliosis, heart failure) is not proven safe and effective.

Peroneal nerve stimulators (examples: NESS L300, NESS L300 Plus, L300 Go System, WalkAide, Odstock [ODFS®] Dropped Foot Stimulator) are medically necessary when used for incomplete spinal cord injury. The evidence and policy language indicate that these devices have not been proven safe and effective for any indication other than incomplete spinal cord injury, and therefore use for other diagnoses should not be considered medically necessary. Examples of non-covered or unproven uses include, but are not limited to, foot drop due to cerebral palsy, multiple sclerosis, traumatic brain injury, or stroke.

Neuromuscular electrical stimulation (NMES) applications that are not specified in this policy are considered not proven safe and effective and therefore not medically necessary. The policy explicitly lists examples of such unsupported indications, including idiopathic scoliosis and heart failure, and indicates that NMES use for these and similar conditions should be denied as not meeting medical necessity criteria.

Coding and Procedure Codes

Covered HCPCS codes referencedHCPCSCovered

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.

HCPCS codes that do not support coverage criteriaHCPCSNot Covered

E0744

Neuromuscular stimulator for scoliosis

inv-09: FES training sessions — >= 32 sessions over a 3-month period

Minimum training sessions>= 32 physical therapy sessions with the device over a three-month period

Purpose of trainingSuccessful completion required prior to approval for FES for walking

TimeframeTraining program must occur over a three-month period

Associated requirementMember must be highly motivated, committed, and cognitively able to use FES for walking

inv-18: HCPCS E0764 definition — functional neuromuscular stimulation device description

HCPCS codeE0764

Short descriptionFunctional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control

Intended use per descriptionUsed for walking by spinal cord injured, entire system, after completion of training program

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required and must document that the member meets medical necessity criteria for NMES/FES/peroneal stimulators. Requests that do not meet the medical necessity criteria in this policy may be denied.

Prior authorization required for NMES, FES, and peroneal nerve stimulators
Denial risk if documentation does not meet policy medical necessity criteria

Note

Rehabilitation Program Expectation

Devices are expected to be used as components of a comprehensive rehabilitation program. FES for walking requires training and demonstrated completion of a device-specific training program (see policy criteria).

NMES must be part of a comprehensive rehab program for disuse atrophy with intact nerve supply
FES for walking requires successful completion of a training program (minimum 32 physical therapy sessions over three months) and rehabilitation commitment

Documentation Required

Required Documentation

Documentation must demonstrate that the device use meets the specific medical necessity criteria in this policy. Include clinical findings, prior conservative therapy, details of nerve/muscle integrity, indication-specific requirements (e.g., timing since injury, contraindications), and evidence of participation in and response to a rehabilitation program.

For NMES: documentation of intact nerve supply to the atrophied muscle and specific atrophy indication (e.g., contracture, prior casting/splinting, post-surgical scenarios)
For FES (SCI): documentation of brisk muscle contraction and sensory perception to stimulation, ≥6 months since recovery from SCI/restorative surgery, motivation and cognitive ability, completion of ≥32 PT sessions with device over 3 months, willingness for long-term use, absence of contraindications (e.g., pacemaker, severe scoliosis/osteoporosis, skin disease/cancer at stimulation site, irreversible contracture, autonomic dysreflexia), and if lower extremity FES requested, intact lower motor units (L1 and below), adequate muscle/joint stability for weight bearing, demonstrated independent transfers and standing tolerance ≥3 minutes, and hand/finger function to manipulate controls
For peroneal nerve stimulators: documentation supporting incomplete spinal cord injury indication; other indications lack proven safety/effectiveness
Include device model and corresponding HCPCS when applicable and clinical rationale tying device to policy criteria

Denial Risk

Denial Risk for Unmet Criteria

Requests that do not meet the medical necessity criteria described in this policy are at risk for denial. Use of HCPCS E0744 (neuromuscular stimulator for scoliosis) does not by itself support coverage and may be denied if criteria are not met.

Denial risk for requests not meeting all policy criteria
HCPCS E0744 does not support coverage criteria for NMES/FES and may be denied

Background and Clinical Context

Neuromuscular electrical stimulation transmits electrical impulses via surface electrodes to the skin over selected muscle groups to elicit muscle contractions. NMES is used to treat disuse atrophy or to augment muscle strength as part of a comprehensive rehabilitation program, typically as an adjunct to active exercise and physical or occupational therapy.

Definitions

inv-16: NMES definition — Neuromuscular electrical stimulation: electrical impulse to skin over selected muscle groups to elicit contractions

DefinitionNeuromuscular electrical stimulation (NMES): transmission of electrical impulses to the skin over selected muscle groups via electrodes to elicit muscle contractions

Primary clinical useTreat muscle atrophy or augment muscle function

Intensity levelsCan be performed at low, medium, or high intensity to elicit mild to strong contractions

inv-17: FES definition — Functional electrical stimulation: activation of muscles to produce functional movements (e.g., standing, walking)

DefinitionFunctional electrical stimulation (FES): application of electrical stimulation to activate muscles to produce functional movements such as standing and walking

Typical indicationsUsed to produce functional movement patterns in patients with upper motor neuron lesions (e.g., paraplegia)

LimitationsNot normally suitable for patients with lower motor neuron lesions