RetiredUnitedHealthcarePolicy CS036LA.V

Electrical Stimulation Treatment Pain Muscle Rehabilitation La Cs

Defines medical necessity and noncoverage determinations for multiple electrical stimulation modalities (TENS, FES, NMES, and others) for members of UnitedHealthcare Community Plan in Louisiana; includes clinical criteria for FES and NMES and lists unproven modalities and applicable procedure/supply codes.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical Stimulation Treatment Pain Muscle Rehabilitation La Cs

Policy CodePolicy CS036LA.V

Change TypeRetired; coding and coverage clarifications

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionDocument required clinical criteria (patient selection, objective measures, prior therapies, and detailed device/parameter rationale) when requesting coverage, per provider documentation guidance.

SourceLink

POLICY UPDATE CHANGES

Policy status indicates the document was retired April 1, 2026.

Added notation that HCPCS codes A4438, A4556, A4557, A4593, and A4594 are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program.

Removed notation indicating HCPCS code E0770 is not on the State of Louisiana Medicaid Fee Schedule and therefore not covered by the State of Louisiana Medicaid Program.

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information and archived previous policy version CS036LA.U.

11FES required candidate criteria

12Modalities unproven/not necessary

Coverage Summary

Defines medical necessity and noncoverage determinations for multiple electrical stimulation modalities (TENS, FES, NMES, and others) for members of UnitedHealthcare Community Plan in Louisiana. Policy status: RETIRED (policy retired April 1, 2026). Effective date range: July 1, 2025 – March 31, 2026. Retirement note: policy retired 04/01/2026; Louisiana plan membership disenrolled on Apr. 1, 2026.

Key thresholds and quick facts

Independent standing tolerance>= 3 minutes

Post-recovery / post-restorative surgery interval>= 6 months

HCPCS codes removed / not on LA Medicaid Fee ScheduleA4438, A4556, A4557, A4593, A4594 — not covered

Policy status / retirement dateRetired April 1, 2026; Louisiana membership disenrolled Apr. 1, 2026

Effective date range (document)Effective July 1, 2025 - March 31, 2026

Medical-Necessity Criteria

Functional Electrical Stimulation (FES) - Medically Necessary

Functional electrical stimulation (FES) is proven and medically necessary as a component of a comprehensive ambulation rehabilitation program in individuals with lower limb paralysis due to spinal cord injury (SCI) when ALL of the following criteria are met:

ALL of the following

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.
Demonstration of brisk muscle contraction.
Demonstration of sensory perception sufficient for muscle contraction.

Provider Actions & Documentation Requirements

Documentation Required

FES candidate documentation

Candidates for functional electrical stimulation (FES) must have documentation supporting device appropriateness and prior training. Include objective clinical findings and trial results when applicable.

Affected codes: E0764, E0770
Document diagnosis and indication for FES (e.g., lower limb paralysis due to spinal cord injury).
Demonstrate intact lower motor units (L1 and below) — both muscle and peripheral nerves.
Document muscle and joint stability for weight bearing and ability to maintain upright support posture independently.
Record demonstration of brisk muscle contraction and sufficient sensory perception for muscle contraction.
Document patient's motivation, cognitive ability, and commitment to device use.
Evidence of ability to transfer independently and independent standing tolerance for at least 3 minutes.
Document hand and finger function adequate to manipulate device controls.
Confirm post-recovery from SCI and restorative surgery of at least 6 months.

Coding (reference lists)

Procedure Codes (reference only)CPT

0278T	Transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes)
0720T	Percutaneous electrical nerve field stimulation, cranial nerves, without implantation
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, percutaneous spinal neurostimulator electrode array, including fluoroscopy, when performed
63664	Revision including replacement, plate/paddle spinal neurostimulator electrode(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
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator; initial electrode array

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Procedure Codes (reference only) - Implantable/functional system notesCPT

E0764	Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, 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 / DME / Supply Codes (reference only)HCPCS

A4438	Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each
A4543	Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
A4544	Electrode for external lower extremity nerve stimulator for restless legs syndrome
A4556	Electrodes (e.g., apnea monitor), per pair
A4557	Lead wires (e.g., apnea monitor), per pair
A4593	Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, controller
A4594	Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece, each
A4595	Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
E0720	Transcutaneous electrical nerve stimulation (TENS) device, two-lead, localized stimulation
E0721	Transcutaneous electrical nerve stimulator for nerves in the auricular region

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HCPCS / DME / Supply Codes (reference only) - Fee schedule notationsHCPCS

(A4438, A4556, A4557, A4593, A4594)

Codes noted in policy as not on the State of Louisiana Medicaid Fee Schedule and therefore not covered by the State of Louisiana Medicaid Program (see policy applicable codes)

FDA Product Codes and References (informational)mixed

GZI	Product code for Functional Electrical Stimulation (search PMN site)
IPF	Product code for NMES for muscle rehabilitation (search PMN site)
LIH	Product code for Interferential Therapy devices (search PMN site)
NHI	Product code for Percutaneous/Peripheral Nerve Stimulation and PENS devices (search PMN site)
PZR	Product code for Peripheral Subcutaneous Field Stimulation / PNFS devices (search PMN site)
GZJ	Product code for TENS/MENS/Scrambler devices (search PMN site)
NUH	Product code referenced for TENS devices
NGX	Product code referenced for TENS devices
QHH	Product code for IB-Stim (PENFS) FDA de novo (pediatric IBS indication)
QLK	Product code for ReActiv8 Implantable Neurostimulation System (PMA)

HCPCS codes noted as not on Louisiana Medicaid Fee Schedule (therefore not covered by State of Louisiana Medicaid Program)HCPCSNot Covered

A4438
A4556
A4557
A4593
A4594

Background & Evidence Summary

Policy background defines and describes the covered modalities within the scope of the document for Louisiana-only application: functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS/PNT), percutaneous electrical nerve field stimulation (PENFS), percutaneous peripheral nerve stimulation (PNS), peripheral subcutaneous field stimulation / peripheral nerve field stimulation (PSFS/PNFS), interferential therapy (IFT), microcurrent electrical nerve stimulation (MENS), pulsed electrical stimulation / pulsed electromagnetic field (PES/PEMF), restorative neurostimulation, scrambler therapy, and translingual stimulation (PoNS/TLNS). The document summarizes intended physiologic mechanisms and therapeutic roles for these modalities (for example: FES to elicit purposeful muscle contractions via intact motor neurons for therapeutic or functional goals; NMES to cause muscle contractions to promote reinnervation or prevent disuse atrophy; TENS to decrease pain perception via surface electrodes; PENS/PENFS as percutaneous needle-based neuromodulation for pain; PSFS/PNFS targeting subcutaneous fields; IFT delivering medium-frequency pulsed currents for deeper tissue pain modulation; MENS delivering sub-sensorial microampere currents; PES/PEMF proposed to facilitate bone/cartilage repair and modulate inflammation; restorative neurostimulation targeting multifidus for chronic low back pain; scrambler therapy delivering variable non-pain waveforms to modulate neuropathic pain; translingual stimulation targeting cranial nerve input to enhance neuroplasticity). Policy explicitly notes the medical policy applies only to the state of Louisiana.

Evidence summary / clinical conclusions (narrative rather than prescriptive criteria)

Key evidence summaries and narrative clinical conclusions (not prescriptive criteria):

Evidence conclusions

Definitions / Terms

Term	Definition
FES	Functional electrical stimulation: application of current to intact nerve fibers to cause purposeful contraction for therapeutic or functional goals
NMES	Neuromuscular electrical stimulation: transcutaneous currents to cause muscle contractions to promote reinnervation, prevent disuse atrophy, or relax spasms; evokes contractions for strengthening or prevention of atrophy
TENS	Transcutaneous electrical nerve stimulation: surface electrodes to decrease pain perception by inhibiting pain nerve impulses and/or stimulating endorphin release
PENS / PNT	Percutaneous techniques using needles connected to external power source; minimally invasive for pain (PENS) and percutaneous neuromodulation therapy (PNT)
PENFS	Percutaneous electrical nerve field stimulation: auricular/peripheral neuromodulation applied percutaneously to modulate central pain pathways
PNS	Peripheral nerve stimulation (percutaneous or implanted): electrode(s) implanted or placed near a peripheral nerve delivering impulses to disrupt pain signal transmission for analgesia or functional restoration
PSFS / PNFS	Peripheral subcutaneous field stimulation / peripheral nerve field stimulation: electrode arrays implanted within subcutaneous tissue to stimulate a painful field rather than identified neural structures
AFO	Ankle-Foot Orthosis: an orthotic device used to support the foot/ankle; commonly compared with FES for foot drop
CCFES	Contralaterally controlled functional electrical stimulation: stimulation controlled by movements of the contralateral limb
IFT / IFC	Interferential therapy/current: delivers medium-frequency pulsed currents producing low-frequency current for deeper penetration to modulate pain
MENS / MET / FSM	Microcurrent electrical nerve stimulation / microcurrent therapy / frequency-specific microcurrent: very low amplitude (microampere) currents intended for pain relief and wound healing; categorized regulatory as TENS
TEAS	Transcutaneous electrical acupoint stimulation: noninvasive electrical stimulation applied to acupoints
PEMF / PES	Pulsed electromagnetic field / pulsed electrical stimulation: noninvasive electromagnetic or electrical field therapies applied for pain, tissue healing or musculoskeletal conditions
ReActiv8	An implantable restorative neurostimulation system targeting multifidus muscle to treat chronic low back pain (example: ReActiv8)
Scrambler Therapy (ST)	A noninvasive neuromodulation therapy (Calmare) delivering cutaneous stimulation with variable waveforms to reduce chronic neuropathic pain
PoNS / TLNS	Portable Neuromodulation Stimulator / Translingual neural stimulation: a mouthpiece device delivering stimulation to the tongue to treat gait/balance deficits as adjunct to supervised exercise
Restorative neurostimulation	Implanted neuromuscular stimulation targeting lumbar multifidus (e.g., ReActiv8) intended as rehabilitative therapy for mechanical CLBP associated with multifidus dysfunction

Medicare & Other Determinations

Name	Effective Year	Type/Notes
CMS PDAC verified FES devices for E0770		Note: The only FES devices verified by CMS PDAC to be reported with HCPCS E0770 include NESS L300/H200 (Bioness), Odstock ODFS Pace, WalkAide, and Drive Medical Deluxe Digital EMS
NICE guideline: Rehabilitation after traumatic injury	2022	Informational: NICE states that additional techniques and specialized equipment (such as FES) should be considered to promote mobility and independent walking after SCI
Functional Electrical Stimulation (FES) - Coverage and HCPCS Coding - NCD		U.S. CMS determination on FES coverage and HCPCS coding (National Coverage Determination/PDAC guidance) referenced in policy; guidance about E0770 coding and device verification

Revision History

2025-07-01revised

Added notation that HCPCS codes A4438, A4556, A4557, A4593, and A4594 are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program; removed notation indicating HCPCS code E0770 is not on the State of Louisiana Medicaid Fee Schedule and therefore not covered; updated Description of Services, Clinical Evidence, FDA, and References sections; archived previous policy version CS036LA.U.

2025-07-01revised

Applicable Codes list updated to include HCPCS/DME/supply codes and note which codes are not on the State of Louisiana Medicaid Fee Schedule (asterisked codes); clarified E0770 device verification list by CMS PDAC.

2025-07-01removed

Policy Summary

PayerUnitedHealthcare

PolicyElectrical Stimulation Treatment Pain Muscle Rehabilitation La Cs

Policy CodePolicy CS036LA.V

Change TypeRetired; coding and coverage clarifications

Effective DateJuly 1, 2025

Next Review DateN/A

SourceLink

On This Page

Neuromuscular Electrical Stimulation (NMES) - Medically Necessary

Neuromuscular electrical stimulation (NMES) is proven and medically necessary when ANY of the following indications are met:

ANY of the following

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 (for example 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.

Neuromuscular Electrical Stimulation (NMES) - Not Medically Necessary

NMES is unproven and not medically necessary for any use outside the indications listed in the NMES medically necessary criteria above.

ALL of the following

Any NMES use or indication not meeting the NMES medically necessary criteria listed above.

Other Electrical Stimulation Modalities - Not Medically Necessary

The following electrical stimulation modalities are unproven and not medically necessary due to insufficient evidence of efficacy for the listed indications (any operator):

ALL 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 electrical stimulation (PES).
Restorative neurostimulation.
Scrambler therapy (ST) / Transcutaneous electrical modulation pain reprocessing.
Translingual stimulation for gait rehabilitation (TS).

Usage notes and limitations

Usage notes and limitations:

ALL of the following

FES coverage applies only when all FES medically necessary criteria are documented in the medical record, including objective demonstration of the listed functional abilities and timelines (standing tolerance and post-recovery duration).
NMES coverage applies only for the specified indications and when documentation supports intact nerve supply for disuse atrophy or inclusion within a comprehensive rehabilitation program for post-TKA or post-stroke therapy.
Devices verified by CMS PDAC to report HCPCS E0770 (e.g., NESS L300/H200, Odstock ODFS Pace, WalkAide, Deluxe Digital Electronic Muscle Stimulator) should be billed with appropriate HCPCS codes; verification does not alone establish medical necessity without meeting clinical criteria.
Services and supplies listed as unproven/not medically necessary will be denied as not medically necessary when used for the listed unproven indications. Refer to related policies for overlap (for example, occipital nerve stimulation or DRG stimulation policies).
Prior authorization and documentation requirements may apply per payer procedures; ensure supporting clinical records, rehabilitation program details, and evidence of failed or inapplicability of alternative therapies are submitted when applicable.

Documentation Required

NMES candidate documentation

For neuromuscular electrical stimulation (NMES) candidates, document the clinical indication, intact nerve supply, and use as part of a comprehensive rehabilitation program when applicable.

Affected codes: E0731, E0744, A4595
Document diagnosis and indication (e.g., disuse muscle atrophy with intact nerve supply; post-TKA rehabilitation; improving upper extremity function post-stroke as part of comprehensive rehab).
Confirm nerve supply to the target muscle is intact and atrophy is not neurological in origin when treating disuse atrophy.
Include documentation of comprehensive rehabilitation plan and NMES role within that plan.
For dysphagia treatment with NMES, follow special arrangements per NICE — clearly document adherence to NICE recommendations and rationale for NMES use in dysphagia.

Documentation Required

NICE special arrangements for dysphagia (Provider action 2)

When using NMES for dysphagia, providers must follow special arrangements referenced by NICE. Document that NICE-recommended safeguards, patient selection criteria, monitoring plans, and outcome measures were followed.

Provider action index: 2
Include specific documentation of adherence to NICE special arrangements for dysphagia (patient selection, informed consent, monitoring, and outcome tracking).
If deviating from NICE guidance, document clinical rationale and supporting evidence.

Documentation Required

Evidence-based rationale and documentation for PENS/PENFS/TEAS/MENS (Provider action 3)

Provide an evidence-based rationale for use of PENS, PENFS, TEAS, MENS or other percutaneous/minimally invasive stimulation techniques. Documentation should reference clinical indications, expected outcomes, and supporting literature when used in coverage requests.

Provider action index: 3
For PENS/PENFS/TEAS/MENS, include: clinical indication, prior conservative treatments tried, proposed treatment plan, expected benefit, duration and frequency, and citations to peer-reviewed evidence supporting efficacy.
If requesting coverage for an unproven indication, include robust justification and comparative evidence.

Documentation Required

Evidence limitations and case review expectations (Provider action 4)

Recognize evidence limitations for many electrical stimulation modalities. Cases that fall outside established criteria should undergo careful, individualized case review prior to authorization.

Provider action index: 4
Document why the patient is being considered despite limited evidence, including severity, prior therapies, and anticipated benefit.
Attach supporting clinical notes and relevant outcome measures for case-by-case review.

Documentation Required

Evidence justification required for coverage requests (Provider action 5)

When requesting coverage for services or devices with limited or mixed evidence, include explicit evidence justification and comparative information to support medical necessity.

Provider action index: 5
Supply literature citations, summary of outcomes, prior conservative management, and objective measures demonstrating need.
State the specific question the requested therapy/device is intended to address and expected measurable outcomes.

Documentation Required

FDA device-reference verification (Provider action 6)

Verify device coding and claims against FDA and CMS device verifications where applicable. Confirm PDAC verification for FES devices billed to HCPCS E0770/E0764 and document the device model.

Provider action index: 6
Document manufacturer, device model, and any FDA clearance/approval information.
For devices reported with HCPCS code E0770/E0764, include PDAC/CMS verification references when available.

Documentation Required

Interpret study limitations (Provider action 7)

Interpret study limitations carefully when relying on clinical literature. Note applicability to the patient population, study size, duration, outcome measures, and risk of bias.

Provider action index: 7
Document how referenced studies apply to the member's case and any limitations (small sample size, short follow-up, surrogate outcomes).
Explain how these limitations were considered in clinical decision-making.

Documentation Required

Reference federal/state/contractual requirements (Provider action 8)

All coverage and payment determinations are subject to federal, state, and contractual requirements. Providers must supply documentation demonstrating how requests meet applicable laws, state Medicaid rules, and UnitedHealthcare contract terms.

Provider action index: 8
Reference applicable federal/state/contractual requirements when submitting requests (e.g., Louisiana Medicaid exclusions, state fee schedules).
If a code is not on the Louisiana Medicaid Fee Schedule, note potential noncoverage per state policy.

Documentation Required

Use of third-party criteria (Provider action 9)

UnitedHealthcare may apply third-party criteria (e.g., InterQual) for medical necessity determinations. When applicable, document alignment with those criteria in submissions.

Provider action index: 9
If InterQual or other external criteria are relevant (for example, TENS criteria), indicate where the patient's presentation meets those criteria.
Attach InterQual or other third-party decision support outputs if used to support the request.

Documentation Required

Policy retirement impact for Louisiana members (Provider action 10)

This policy is retired for Louisiana effective April 1, 2026. For members whose care spans the retirement date, document continuity of care needs and any transitional coverage requests with dates and justification.

Provider action index: 10
Retirement impact date: April 1, 2026
Document transitional care plans and any pending authorizations that cross the retirement date; include dates of service and rationale for continuation.

NMES summary: NMES: systematic reviews and RCTs show small effects on muscle strength, walking performance and functional mobility; moderate effect on muscle size; evidence heterogeneous and limited by small sample sizes and bias.
NMES post-op older adults: NMES in post-surgical older adults (Takino 2023): short course (post-op day 1–7, daily 60 minutes) mitigated postsurgical muscle weakness and functional decline; stronger effect in participants ≥75 years.
NMES ICU evidence: NMES in ICU/critically ill older adults: evidence suggests reduction in muscle atrophy/thickness and potential improvements in muscle strength and shorter ventilation/LOS in some meta-analyses, but individual trials show mixed results and limitations.
NMES dysphagia: NMES for dysphagia: systematic reviews find insufficient/low-quality evidence; NICE recommends use only with special arrangements for governance/research.
IFT summary: IFT: evidence inconsistent; some meta-analyses show short-term pain and function improvements in NSCLBP and knee OA, but other RCTs show no benefit; NICE recommends against offering IFT for OA, chronic primary pain, and LBP due to insufficient evidence.
MENS summary: MENS (microcurrent): small RCTs/meta-analyses suggest modest pain reductions in limited conditions; overall evidence limited by small samples and heterogeneity.
Overall limitations across modalities: small trials, heterogeneity in protocols (parameters, dose, frequency), short follow-up, variable risk of bias, and lack of large high-quality RCTs; guideline bodies generally conclude insufficient evidence to broadly recommend many modalities.

Authors caution that the evidence across many studies and modalities is limited by small sample sizes, heterogeneous protocols (parameters, dosing, and frequencies), short follow-up, variable risk of bias, and participant heterogeneity; these limitations restrict generalizability and interpretation of clinical relevance. Recommended further research includes larger, well-designed RCTs, standardized stimulation parameters, longer-term follow-up, and studies to define patient selection and dosing. The policy also emphasizes that FDA approvals/clearances and product regulatory categorizations are provided for informational purposes only and that FDA status alone is not a basis for coverage determination.

Citation / Source	Key finding/summary
Hayes EARB (2024)	Home-based FES for SCI had insufficient peer-reviewed literature; no clear support
Máté et al. (2023)	Systematic review: hybrid FES cycling improved VO2peak vs arm crank ergometry; small studies and limitations
Bekhet et al. (2022)	Systematic review: NMES/FES increased muscle cross-sectional area (avg +26%); evidence limited by heterogeneity and small samples
Sadowsky et al. (2013)	Cohort: FES cycling associated with CMSS improvement and muscle mass/strength gains vs ROM/stretching controls
Hayes HTA (2022a, updated 2024)	Low-quality evidence; inconsistent benefit of FES for foot drop in acute/subacute stroke; recommends more RCTs
Hayes HTA (2022b, updated 2024)	Low-quality evidence for skin-surface FES in chronic stroke; very low for implanted electrodes; no significant improvements vs AFOs
ECRI CEA (2022)	FNMS improved hand function as supplement in chronic post-stroke; evidence limited and heterogeneous
Jaqueline da Cunha et al. (2021) meta-analysis	FES alone did not enhance gait speed vs conventional; FES + supervised exercises improved gait speed and other measures; low-quality evidence
Jonsdottir et al. (2017) RCT	MeCFES added to task-oriented therapy showed small UE improvements; safety acceptable; limited by incomplete sample size
Kadoglou et al. (2017) RCT CHF	Six-week FES reduced HF-related hospitalizations vs placebo; no mortality difference
Wang et al. (2022a) meta-analysis CHF	FES improved peak VO2, 6MWT, QOL vs control; muscle strength not significantly improved
Zeng et al. (2024) meta-analysis CHF	FES improved peak VO2, 6MWT, QOL vs control but less effective than traditional exercise rehab
Waldauf et al. (2021) ICU RCT	FES-assisted cycling did not improve physical disability at 6 months for mechanically ventilated ICU patients
Fossat et al. (2018) ICU RCT	Early in-bed leg cycling + ES did not improve global muscle strength at ICU discharge
NMES evidence summary	Some support for NMES to treat disuse atrophy when nerve intact; limited evidence for dysphagia, ICU-AW, and DVT/edema prevention after THR
THR edema feasibility RCT (Wainwright et al., 2018)	NMES group had less knee and thigh edema; small single-center study; safe and well tolerated
TKA RCT (Stevens-Lapsley et al., 2012)	NMES initiated 48 hours post-op improved quadriceps/hamstring strength and functional performance early; benefits persisted to 1 year though attenuated
Amputee pilot RCT (Talbot et al., 2017)	Home-based NMES + rehab improved residual limb strength and pain early vs rehab alone; differences diminished post-prosthesis
CP reviews and RCTs (Greve 2022; Cobo-Vicente 2021; Pool 2016; Abd Elmonem 2024)	NMES shows potential benefits for strength, gait, muscle volume and function in pediatric/adolescent CP; heterogeneous protocols
Post-stroke dysphagia meta-analyses (Wang 2023; Alamer 2020)	NMES + swallowing therapy improved swallowing function and QOL in pooled analyses; heterogeneity and study quality concerns
Post-stroke motor function (Kristensen 2021; multiple RCTs)	Meta-analysis showed positive effect on ADLs (SMD 0.41); subgroup benefits when applied subacute and to UE; mixed effects on motor ability
CCFES vs NMES (Knutson 2016; Shen 2015)	CCFES showed improved manual dexterity or UE function compared to cyclic NMES in some trials
COPD and ventilated patients (Gutiérrez-Arias 2022; Wu 2020; Hill 2018)	Evidence mixed: NMES may improve quadriceps strength, 6MWD, and reduce MV time in some studies; overall evidence low/very low quality
Hospitalized patients preventing acquired disability (Alqurashi 2023)	Small to moderate pooled effects on muscle strength, walking performance, and muscle size; heterogeneity and risk of bias substantial
Takino et al. 2023 RCT	180 adults; NMES post-op day 1–7 daily 60 min mitigated postsurgical muscle weakness; stronger effect in ≥75 years
Sun et al. 2020 (dysphagia)	11 studies; evidence low to very low; no firm conclusion on efficacy
Liu et al. 2020 (ICU-AW)	11 RCTs; NMES may improve strength, shorten ventilation time and LOS, increase walking distance
IFT systematic reviews/meta-analyses	Mixed: some moderate-quality evidence for immediate post-treatment pain reduction in NSCLBP and knee OA; other RCTs show no long-term benefit; NICE recommends against offering IFT for OA, chronic primary pain, and LBP
MENS systematic reviews	Small RCTs/meta-analyses suggest modest pain reductions for masticatory myofascial pain and possible benefits for shoulder/knee pain versus sham; evidence limited
Overall limitations and guideline positions	Small trials, heterogeneous protocols, short follow-up and variable bias; guideline bodies generally conclude insufficient evidence for many modalities
Hayes, ECRI, ASCO, NICE summaries	Technology assessments generally conclude insufficient or inconclusive support for several devices/indications and call for larger RCTs
ReActiv8 RCT and follow-ups (Gilligan et al. 2021/2022/2023/2024)	Multiple RCTs and follow-ups report clinically meaningful improvements but limitations include attrition, lack of independent controls; HTAs deem evidence inconclusive
Scrambler Therapy RCTs/meta-analyses (Jin 2022, Kashyap 2022, Lee 2022, Chung 2024)	Mixed small RCTs and pilot studies; marginal short-term pain reductions; evidence low quality and insufficient per Hayes and guideline bodies
PoNS/TLNS evidence (Ptito 2021; Tyler 2019; Hou 2022)	3 RCTs + small studies: TLNS+PT produced improvements in balance/gait but both active and control arms often improved; evidence inconclusive and further studies needed
References count (policy)	Numerous peer-reviewed randomized trials, systematic reviews, meta-analyses, and guideline citations (NICE, AHA/ASA, ACP) listed