CurrentUnitedHealthcarePolicy MMP090.16

Electrical Stimulators

UnitedHealthcare Medicare Advantage policy (MMP090.16) governing coverage references, applicable CPT/HCPCS codes, and CMS LCD/LCA applicability for multiple types of electrical stimulation therapies (auricular acupuncture points, dysphagia, occipital nerve stimulation, PENS/PNT, implanted/percutaneous peripheral nerve stimulation, vagus nerve stimulation) for members in specified states/territories.

Policy Summary

PayerUnitedHealthcare

PolicyElectrical Stimulators

Policy CodePolicy MMP090.16

Change TypeCodes removed; references updated

Effective DateMay 1, 2025

Next Review Date

Key ActionProviders must comply with applicable Medicare LCDs/LCAs for electrical stimulation services where they exist and retain documentation to support coverage when requested.

POLICY UPDATE CHANGES

Added reference link to UnitedHealthcare Medicare Advantage Medical Policy titled Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital.

Added references to UnitedHealthcare Commercial Medical Policies: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation; Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache); and Vagus and External Trigeminal Nerve Stimulation.

Removed CPT/HCPCS codes 64553 and E0745 from Applicable Codes.

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

Archived previous policy version MMP090.15.

6Electrical stimulation topics referenced

8CPT/HCPCS codes listed

2Codes removed in this revision

Coverage Summary

UnitedHealthcare Medicare Advantage policy MMP090.16 provides coverage references, lists applicable CPT/HCPCS codes, and describes CMS LCD/LCA and NCD applicability for multiple electrical stimulation therapies (auricular acupuncture points, dysphagia, occipital nerve stimulation, PENS/PNT, implanted/percutaneous peripheral nerve stimulation, vagus nerve stimulation). Effective date: 05/01/2025; Last review/committee approval date: April 9, 2025. The policy directs providers to follow applicable Medicare NCDs/LCDs where they exist and to refer to UnitedHealthcare commercial/internal policies when Medicare guidance is not available. Benefit coverage is determined by the member-specific benefit plan document, which prevails in the event of a conflict.

Key facts

Policy numberMMP090.16

Coverage stancemixed

StatusCURRENT

Electrical stimulation topics referenced6

CPT/HCPCS codes listed8

Codes removed in this revision2

Referenced CPT/HCPCS codes (examples)61885, 61886, 63650, 64555, 64590, 64999, E0764, E0770

Medical-Necessity Criteria

General Medicare/LCD Compliance and Referral

Coverage depends on applicable Medicare NCDs/LCDs and internal criteria where no NCD/LCD exists:

ALL of the following

Where no specific Medicare NCD exists: Where a specific Medicare NCD does not exist, applicable LCDs/LCAs (where present) must be followed.
Refer to commercial policy when no LCD/LCA: For states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled 'Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation' or other listed related commercial policies as applicable.
Implanted peripheral nerve stimulation coverage: Implanted peripheral nerve stimulation is covered when criteria are met per NCD for Electrical Nerve Stimulators (160.7).

Applicable and Removed Codes

Referenced CPT codesCPT

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]

Referenced HCPCS codesHCPCS

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

Removed codes in this revisionmixedNot Covered

64553	Removed from Applicable Codes (previously listed)
E0745	Removed from Applicable Codes (previously listed)

Inclusion of procedure or diagnosis codes and references in this policy is for reference only and does not guarantee reimbursement. Benefit coverage is determined by the member's specific benefit plan document and applicable laws; providers must follow those plan terms to determine coverage and payment.

Provider Actions & Billing Guidance

Documentation Required

Follow applicable LCDs/LCAs and retain documentation

Providers must comply with applicable Medicare LCDs/LCAs for electrical stimulation services where they exist and retain documentation to support coverage when requested.

Documentation Required

Refer to UnitedHealthcare commercial policies when no LCD/LCA

For jurisdictions without LCDs/LCAs, providers must follow the referenced UnitedHealthcare Commercial Medical Policies (e.g., Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation) to determine coverage criteria.

Medicare NCDs / LCDs / LCAs Referenced

Type (NCD/LCD/LCA)	Number	Name
NCD	160.7	Electrical Nerve Stimulators
LCD	L34578	Surface Electrical Stimulation in the Treatment of Dysphagia
LCA	A56584	Billing and Coding: Surface Electrical Stimulation in the Treatment of Dysphagia
LCD	L34565	Home Health - Surface Electrical Stimulation in the Treatment of Dysphagia
LCA	A56648	Billing and Coding: Home Health - Surface Electrical Stimulation in the Treatment of Dysphagia
LCD	L34328	Peripheral Nerve Stimulation
LCA	A55530	Billing and Coding: Peripheral Nerve Stimulation
LCD	L37360	Peripheral Nerve Stimulation
LCA	A55531	Billing and Coding: Peripheral Nerve Stimulation
LCA		Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device)

Background

This Medicare Advantage policy lists coverage references and applicable CPT/HCPCS codes for various electrical stimulation therapies and instructs providers to follow Medicare NCDs/LCDs where present. Where no Medicare guidance exists, UnitedHealthcare internal or commercial policies are cited as guidance (for example, policies for electrical stimulation for pain and muscle rehabilitation, occipital nerve injections/ablation, and vagus/external trigeminal nerve stimulation). The policy is provided for informational purposes and the member-specific benefit plan document governs final coverage determinations.

Electrical stimulation of auricular acupuncture points: Also known as electro-acupuncture stimulation, peripheral subcutaneous field stimulation (PSFS), or peripheral nerve field stimulation (PNFS).

Revision History

05/01/2025added

Added reference link to UnitedHealthcare Medicare Advantage Medical Policy titled Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital.

05/01/2025added

05/01/2025removedLatest