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Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
05.00.73g


Policy

NEUROMUSCULAR ELECTRICAL STIMULATOR FOR MUSCLE ATROPHY

MEDICALLY NECESSARY
A neuromuscular electrical stimulator (NMES) (Healthcare Common Procedure Coding System [HCPCS] code E0745) is considered medically necessary and, therefore, covered for the treatment of muscle atrophy for conditions in which the nerve supply to the muscle is intact and the individual has a non-neurological indication causing disuse atrophy as documented in the individual's medical record. These indications include but are not limited to the following:
  • Casting or splinting of a limb
  • Contracture due to scarring of soft tissue (e.g., due to burn)
  • Recent hip surgery until the individual begins physical therapy
SUPPLIES FOR NMES
Replacement supplies are considered medically necessary and, therefore, covered when used with a medically necessary NMES. The usual maximum utilization for supplies are:
  • 2-lead NMES device — a maximum of one unit of A4595 per month (12 per year)
  • 4-lead NMES device — a maximum of two units of A4595 per month (24 per year)
  • Replacement of lead wires (A4557) — typically once every 12 months
A NMES supply allowance (A4595) includes electrodes (any type) (A4556), conductive paste or gel (if needed, depending on the type of electrode) (A4558), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (9-volt or AA, single use or rechargeable) (A4630), and a battery charger (if rechargeable batteries are used). Therefore, these items will not be eligible for separate reimbursement if reported on the same date of service or within 30 days of A4595.

At the time of a NMES unit (E0745) purchase, the reimbursement for the NMES unit includes reimbursement for lead wires and 1 month’s supply of electrodes, conductive paste or gel (if needed), and batteries.
EXPERIMENTAL/INVESTIGATIONAL
All other uses for NMES for muscle atrophy, including use where the nerve supply to the muscle is not intact, are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

NOT MEDICALLY NECESSARY
Conductive Garment used with NMES

 A conductive garment used with NMES (HCPCS code E0731) is considered not medically necessary and, therefore, not covered because NMES can effectively be delivered through the use of conventional electrodes, adhesive tapes, and lead wires. However, a conductive garment may be considered medically necessary and, therefore, covered if one of the following criteria are met:
  • The individual cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires.
  • The individual cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires.
  • The individual has a documented medical condition such as a skin condition that precludes the application of conventional electrodes, adhesive tapes, and lead wires.
  • The individual requires electrical stimulation underneath a cast either to treat disuse atrophy, in which the nerve supply to the muscle is intact, or to treat chronic intractable pain.
  • The individual has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury in which the nerve supply to the muscle is intact.​
FUNCTIONAL ELECTRICAL STIMULATOR (FES) FOR INDIVIDUALS WITH SPINAL CORD INJURY (SCI) (i.e., PARASTEP® AMBULATION SYSTEM)

MEDICALLY NECESSARY
An FES for SCI (i.e., Parastep® Ambulation System) (HCPCS code E0764) is considered medically necessary and, therefore, covered for individuals who meet all of the following criteria:
  • Intact lower motor units (both muscle and peripheral nerve of L1 and below)
  • Muscle and joint stability for weight bearing of the upper and lower extremities, with demonstration of balance and control to independently maintain an upright posture
  • Demonstration of brisk muscle contraction to NMES and the existence of sensory perception of electrical stimulation sufficient for muscle contraction
  • Possession of high motivation, commitment, and cognitive ability to use the device for walking
  • Ability to transfer independently and demonstrate independent standing tolerance for at least 3 minutes
  • Demonstration of hand and finger function to manipulate the device controls
  • At least 6-month postrecovery from spinal cord injury and restorative surgery
  • Absence of degenerative disease of the hip and knee, and no history of long bone fracture secondary to osteoporosis
  • Demonstration of a willingness to use the device on a long-term basis
In addition to meeting all of the above criteria, individuals with SCI must have completed physical therapy (PT) training with the device. Individual member benefits for PT services must be verified. Benefits for all services related to PT are provided to individuals in accordance with the benefit contract and any applicable state mandates and vary by product and group. Individual member benefits must be verified for specific coverage criteria regarding limits, existing contractual exclusions, and specific state mandate coverage criteria.

EXPERIMENTAL/INVESTIGATIONAL
All other uses for an FES for SCI are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

NOT MEDICALLY NECESSARY
Absolute Contraindications

 An FES for SCI is considered not medically necessary and, therefore, not covered for individuals with any of the following absolute contraindications:
  • Cardiac pacemakers
  • Severe scoliosis or severe osteoporosis
  • Skin disease or cancer at the area of stimulation
  • Irreversible contracture
  • Autonomic dysreflexia
FES FOR FOOT DROP IN INDIVIDUALS WITH SCI (i.e., NESS L300™, WALKAIDE®)

MEDICALLY NECESSARY
An FES for the lower extremities (HCPCS code E0770) with either the WalkAide® or the NESS L300™ system is considered medically necessary and, therefore, covered for SCI individuals with foot drop who meet all of the above criteria for FES (i.e., Parastep® Ambulation System) for SCI.

FES FOR LOWER EXTREMITIES IN INDIVIDUALS WITH ANY NEUROLOGICAL INDICATION OTHER THAN SCI

EXPERIMENTAL/INVESTIGATIONAL
All other types of FES devices and uses for FES for the lower extremities, including use in individuals with foot drop caused by cerebrovascular accident (CVA), multiple sclerosis (MS), or cerebral palsy (CP) are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

FES FOR UPPER EXTREMITIES

EXPERIMENTAL/INVESTIGATIONAL
An FES for the upper extremities (e.g., NESS H200™) (HCPCS code E0770) used to restore function following nerve damage or nerve injury is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published literature. This includes use in individuals with decreased upper extremity function caused by SCI or CVA.

NOT PRIMARILY MEDICAL IN NATURE (BENEFIT CONTRACT EXCLUSION)

FES devices (e.g., RT 300 FES Cycle and ERGYS), which are not primarily intended to enable the individual to ambulate, are not primarily medical in nature (benefit contract exclusion) and, therefore, not covered.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. 

STANDARD WRITTEN REQUIREMENTS

Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written ​order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY (WHEN APPLICABLE)

Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES

The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately ​7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.​
If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

Guidelines

The physical therapy (PT) necessary to train the individual in the use of functional electrical stimulator (FES) for SCI (i.e., Parastep® Ambulation System) or FES for the lower extremities with either the WalkAide® or NESS L300™ system must be performed directly by the physical therapist as part of a one-on-one training program; this service cannot be provided remotely. The physical therapist should be skilled in the use of FES.
  • PT is only available to members enrolled in a Company plan that includes a benefit for this service.
    • Benefit contracts may have variable PT limitations. Individual member benefits must be verified.
    • If a member exceeds benefit maximums or obtains services outside of the benefit contract, the member is financially responsible for all associated charges.
BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, neuromuscular electrical stimulators (NMES) and FES are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous products approved by the FDA for neuromuscular stimulation and functional electrical stimulation.

Description

Neuromuscular electrical stimulation (NMES) involves the use of a device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. There are two broad categories of NMES. One type of device is used to treat muscle atrophy and stimulates the muscle when the individual is in a resting state. The second type, also known as functional electrical stimulation (FES), is used to enhance functional activity of neurologically impaired individuals.

NEUROMUSCULAR ELECTRICAL STIMULATORS FOR MUSCULAR DISUSE ATROPHY

NMES is used as a treatment modality for disuse atrophy due to a condition such as limb casting or hip replacement surgery, in which the nerve supply to the muscle is intact. The NMES device encompasses a portable stimulator with electrodes that are placed on the skin over a targeted muscle or muscle group. The current passes through the electrodes into the body, and the motor nerves are stimulated, causing a muscle contraction. The intensity and frequency of stimulation can vary based on the level of muscular function and response to treatment.

The use of NMES was studied by the Office of Health Technology Assessment (OHTA) at the Public Health Service in cases where neural supply (including brain, spinal cord, and peripheral nerves) to the muscle was intact or where other non-neurological reasons for disuse were causing atrophy. The report excluded clinical situations in which the cause of the disuse was considered permanent or was characterized by a nonreversible pathology. Based on their complete assessment of all relevant literature, OHTA concluded that the use of NMES for the treatment of disuse atrophy is considered effective therapy when the cause of the muscle disuse is not permanent and there is no nervous system involvement. In this situation, the treatment of disuse atrophy was considered a surrogate health outcome (i.e., an intermediate outcome as opposed to an eventual outcome, such as the ability to ambulate), because the treatment of disuse atrophy generally leads to a full recovery of function.

FUNCTIONAL ELECTRICAL STIMULATORS FOR THE TREATMENT OF NEUROMUSCULAR CONDITIONS

The second type of NMES is FES, which is used to enhance functional activity in neurologically impaired patients. The objective of FES is to activate targeted muscle groups to facilitate performance of functional activities (e.g., grasping utensils for feeding) or movements (e.g., ambulation). The use of FES has been primarily proposed for individuals with neurological conditions such as spinal cord injury (SCI), multiple sclerosis (MS), cerebrovascular accident (CVA), and cerebral palsy (CP).

An application of FES is to provide individuals with SCI with the ability to stand and walk. The FES device delivers a precise sequence of electrical pulses to trigger action potentials at selected nerves at the quadriceps (for knee extension), common peroneal nerve (for hip flexion), and the paraspinals and gluteals (for trunk stability). The individual uses a walker or elbow-support crutches for further support. The electrical impulses are controlled by a computer microchip attached to the individual's belt that synchronizes and distributes the signals. Additionally, there is a finger-controlled switch that permits activation of the stepping by the individual. The Parastep® Ambulation System (Therapeutic Alliances, Inc., Fairborn, OH) is the only such device to receive approval by the U.S. Food and Drug Administration (FDA) and is indicated to "enable appropriately selected skeletally mature spinal cord injured patients (level C6-T12) to stand and attain limited ambulation and/or management of spinal cord injury."

Other FES devices have been developed for individuals with foot drop. Foot drop is caused by weakness in the foot and ankle, which is activated by the peroneal nerve, resulting in decreased dorsiflexion and difficulty with ambulation. It can be caused by neurological conditions that include SCI, CVA, MS, and CP. WalkAide® and the Bioness NESS L300™ (Innovative Neurotronics, Inc., Bethesda, MD) are examples of FES devices for foot drop. The NESS L300™ consists of three components: a functional stimulation cuff, a gait sensor, and a wireless control device. The functional stimulation cuff is worn by the individual just below the knee and holds the stimulation device and electrodes. The gait sensor is worn inside the individual's shoe and automatically detects different walking speeds and surfaces and sends a signal to the functional stimulation cuff to adjust the stimulation to the peroneal nerve to allow the individual's gait to be adjusted. The control device allows the individual to turn the NESS L300™ on and off, as well as make minor stimulation adjustments.

Overall, small studies focusing on FES devices for foot drop have been performed but did not demonstrate that the use of such devices provided clinically significant improvement in ambulation. A cross-over study with the use of FES and ankle foot orthosis in individuals with chronic post-stroke foot drop showed improved satisfaction with FES but no change in walking speed. In 2020, a meta-analysis by da Cunha et al. examined 14 crossover studies in post-stroke individuals using FES applied to the peroneal nerve compared to supervised exercise. The combination of FES along with supervised exercises improved gait speed, and showed positive finding of FES on improved ankle dorsiflexion, balance, and mobility. However, the authors warn that their results must be interpreted cautiously as the studies that comprised the meta-analysis were of low-quality evidence and had high heterogeneity. The single randomized controlled trial examining FES for foot drop in individuals with MS did not demonstrate a clinically significant benefit when compared with no stimulation or a program of exercise.​ ​

Tolerability and efficacy of FES was studied over a 3-month period in 10 children with hemiparetic CP who typically wore an ankle foot orthosis for the correction of foot drop (Meilahn, 2013). Gait analysis was performed, but quantitative results were not included in the report. Although half of the children improved gait velocity, mean velocity was relatively unchanged. Another study examined the acceptability and effectiveness of FES in 21 children with CP who had mild gait impairments and unilateral foot drop over a period of 3 months (Prosser et al., 2012). There was no significant change in other gait parameters, including walking speed. Both of the aforementioned studies, which should be considered preliminary, show no improvement in walking speed with the FES device. In addition, daily use decreased over the course of one trial. Studies in a larger number of individuals over a longer duration are needed to permit conclusions concerning the effect of the technology on health outcomes in individuals with foot drop caused by CP.

Another application of FES is to restore upper extremity functions such as grasp-release in individuals with CVA or SCI. An example of an FES device for the upper extremity is the NESS H200™ (Innovative Neurotronics, Inc., Bethesda, MD). It consists of two components: an orthosis and a control device. The orthosis fits on the individual's hand and forearm and maintains the wrist in a position to perform functional hand movements. It has electrodes that are in direct contact with the individual's forearm muscles. The control device has a microprocessor that sends electrical impulses from the control device to the electrodes and stimulates the forearm muscles, causing muscle activation and the ability to pinch, grasp, and release. Based on the review of available peer-reviewed published literature, the evidence for the use of FES devices for an upper extremity is limited by the small number of subjects and limited data demonstrating its utility outside of the clinical setting. The available evidence is insufficient to conclude that FES improves outcomes by providing some upper extremity function.

References

Barrett CL, Mann GE, Taylor PN, et al. A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis. Mult Scler. 2009;15(4):493-504.

Cauraugh JH, Naik SK, Hsu WH, et al. Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation. Clin Rehabil. 2010;24(11):963-78.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 01/01/2020. Available at: https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis.  Accessed June 20, 2023.


Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List, 88 Fed Reg, 2546 (01/17/2023). Available at: https://public-inspection.federalregister.gov/2023-00718.pdf. Accessed June 20, 2023.


Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS) L33802. [CMS Web site]. 11/20/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33802. Accessed June 26, 2023. ​


Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) for neuromuscular electrical stimulation for spinal cord injury (CAG-00153R). Decision memo. [CMS Web site]. 07/22/12. Available at:
http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=55&NcaName=Neuromuscular+Electrical+Stimulation+(NMES)+for+Spinal+Cord+Injury&NCDId=175&IsPopup=y&bc=AAAAAAAACAAAAA==&. Accessed June 20, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 160.12: Neuromuscular Electrical Stimulation (NMES). [CMS Web Site]. 10/01/2006. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=175&ncdver=2&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=neuromuscular+electrical&KeyWordLookUp=Title&KeyWordSearchType=And&ncd_id=160.12&ncd_version=2&basket=ncd:160.12:2:Neuromuscular+Electrical+Stimulaton+(NMES).&bc=gAAAABAAAAAAAA==&. Accessed June 20, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 160.13: Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES). [CMS Web Site]. 07/14/1988. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=151&ncdver=1&CoverageSelection=National&KeyWord=neuromuscular&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Accessed June 20, 2023.


da Cunha JM, Rech KD, Salazar AP, et al. Functional electrical stimulation of the peroneal nerve improves post-stroke gait speed when combined with physiotherapy. A systematic review and meta-analysis. Ann Phys Rehabil Med. 2021;64(1):101388. 

Hamid S, Hayek R. Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview. Eur Spine J. 2008;17(9):1256-1269.

Hausdorff JM, Ring H. Effects of a new radio frequency-controlled neuroprosthesis on gait symmetry and rhythmicity in patients with chronic hemiparesis. Am J Phys Med Rehabil. 2008;87(1):4-13.


​Laufer Y, Hausdorff JM, Ring H. Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity. Am J Phys Med Rehabil. 2009;88(1):14-20.

Meilahn JR. Tolerability and effectiveness of a neuroprosthesis for the treatment of footdrop in pediatric patients with hemiparetic cerebral palsy. PM R. 2013;5(6):503-509.

National Institute for Health and Clinical Excellence. Functional electrical stimulation for drop foot of central neurological origin. [NICE Web site]. 1/2009. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG278Guidance.pdf.
Accessed June 20, 2023.

National Institute for Health and Clinical Excellence. Interventional procedure overview of functional electrical stimulation for drop foot of central neurological origin. [NICE Web site]. 4/2008. Available at: https://www.nice.org.uk/guidance/ipg278/evidence/overview-pdf-310927213. Accessed June 20, 2023.

Prosser LA, Curatalo LA, Alter KE, et al. Acceptability and potential effectiveness of a foot drop stimulator in children and adolescents with cerebral palsy. Dev Med Child Neurol. 2012;54(11):1044-1049.

Ring H, Treger I, Gruendlinger L, et al. Neuroprosthesis for footdrop compared with ankle-foot orthosis: effects on postural control during walking. J Stroke Cerebrovasc Dis. 2009;18(1):41-47.

Sheffler LR, Hennessey MT, Knutson JS, et al. Neuroprosthetic effect of peroneal nerve stimulation in multiple sclerosis: a preliminary study. Arch Phys Med Rehabil. 2009;90(2):362-365.

Stein RB, Everaert DG, Thompson AK, et al. Long-term therapeutic and orthotic effects of a foot drop stimulator on walking performance in progressive and nonprogressive neurological disorders. Neurorehabil Neural Repair. 2010;24(2):152-167.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Handmaster. 510(k) summary. [FDA Web site]. 08/08/03. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/k031900.pdf. Accessed June 20, 2023.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. NESS L300. 510(k) summary. [FDA Web site]. 07/07/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/K053468.pdf. Accessed June 20, 2023.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. WalkAide system. 510(k) summary. [FDA Web site]. 09/21/05. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/K052329.pdf. Accessed June 20, 2023.

van Swigchem R, Vloothuis J, den Boer J, et al. Is trancutaneous peroneal stimulation beneficial to patients with chronic stroke using an ankle-foot orthosis? A within-subjects study of patients' satisfaction, walking speed and physical activity level. J Rehabil Med.2010;42(2):152-167.


Venugopalan L, Taylor PN, Cobb JE, et al. Upper limb functional electrical stimulation devices and their man-machine interfaces. J Med Eng Technol. 2015;39(8):471-479. ​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
MEDICALLY NECESSARY 

THE FOLLOWING CODE IS USED TO REPRESENT NEUROMUSCULAR ELECTRICAL STIMULATORS (NMES):

E0745 Neuromuscular stimulator, electronic shock unit

THE FOLLOWING CODE IS USED TO REPRESENT FUNCTIONAL ELECTRICAL STIMULATORS (FES) FOR INDIVIDUALS WITH SPINAL CORD INJURY (SCI) (PARASTEP® AMBULATION SYSTEM):

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

THE FOLLOWING CODE IS USED TO REPRESENT FES FOR LOWER EXTREMITIES (E.G., NESS
L300™, WALKAIDE®) OR UPPER EXTREMITIES (E.G., NESS H200TM):

E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified

THE FOLLOWING CODES ARE USED TO REPRESENT SUPPLIES ASSOCIATED WITH NMES:

A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)

A4556 Electrodes (e.g., apnea monitor), per pair

A4557 Lead wires (e.g., apnea monitor), per pair

A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz

A4630 Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient

E0731 Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)

BENEFIT CONTRACT EXCLUSION

THE FOLLOWING CODE REPRESENTS OTHER FES DEVICES (E.G., RT 300 FES CYCLE and ERGYS):​
E1399 Durable medical equipment, miscellaneous
Revenue Code Number(s)
N/A



Coding and Billing Requirements

Policy History

Revisions From ​05.00.73g:
07/31/2023

This version of the policy will become effective 07/31/2023


The face-to-face requirements no longer apply to codes:

  • 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 ​
​
Revisions From ​05.00.73f:
01/02/2023
This version of the policy will become effective effective 01/03/2023. This policy has been updated in consideration of CMS revisions. The following policy criteria have been added:
  • ​Face-to-Face requirments, to include specified codes​
    • 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​​​​​​​

Revisions From 05.00.73e:
06/07/2021This version of the policy will become effective 06/07/2021

The following requirements have been deleted from this policy:​
Face-to-face requirements.

Revisions From 05.00.73d:
10/01/2020This policy has been identified for the ICD-10 CM code update effective 10/01/2020.

The following ICD-10 CM codes have been added to Attachment A of this policy as "Experimental/Investigational":
R51.0: Headache with orthostatic component, not elsewhere classified
R51.9: Headace, unspecified

The following ICD-10 CM code has been termed from Attachment A of this policy:
R51.0: Headache

Revisions From 05.00.73c:
01/29/2020The policy has been reviewed and reissued to communicate the Company's continuing position on Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES).
08/01/2018Effective 08/01/2018, this policy was reviewed and reissued to communicate the company's continuing position on Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES).
11/22/2017This policy was reviewed and reissued to communicate the company's continuing position on Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES).

Effective 10/05/2017 this policy has been updated to the new policy template format.
7/31/2023
7/31/2023
05.00.73
Medical Policy Bulletin
Commercial
No
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