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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2015, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-25

Original Effective Date: 09/15/02

Reviewed: 10/22/09

Revised: 09/15/14

Subject: Neuromuscular Electrical Stimulator (NMES)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

A neuromuscular electrical stimulator (NMES) is a two-channel device that transmits electrical impulses through the skin (transcutaneous) to selected muscle groups by way of electrodes. These devices are designed for use in the home for treating muscle atrophy caused by lack of use.

In comparison with a TENS device, a NMES device delivers a stronger electrical current and has a wider pulse width to produce muscle contractions.

There are two categories of NMES. One stimulates the muscle in resting state, used to treat patients with muscle atrophy. The other enhances functional activity in neurologically impaired patients and uses electrical impulses to activate paralyzed or weak muscles in a precise sequence and has been used in the rehabilitation of upper and lower extremities. Neuromuscular electric stimulation used for this application is commonly referred to as functional electric stimulation (FES) and is discussed in a separate guideline.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Neuromuscular Electrical Stimulator to expedite the medical review process.

1. Click the link Neuromuscular Electrical Stimulator (NMES)- Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Refer to MCG 09-E0000-54, Functional Neuromuscular Stimulation for information regarding Bioness L300™.

Neuromuscular electrical stimulators meet the definition of medical necessity when prescribed for the treatment of disuse atrophy when both of the following conditions exist:

Examples of conditions for which NMES devices meet the definition of medical necessity include, but are not limited to:

The application of NMES for other conditions or diagnoses is subject to medical review of documentation that supports medical necessity. The following information may be required documentation to support medical necessity: attending physician visit notes, physician history and physical, surgical operative notes.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative note

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Neuromuscular electrical stimulators do not meet the definition of medical necessity, as they are not the standard of practice for the use of NMES devices when used in the treatment of:

The application of NMES is considered experimental or investigational when used in the treatment of scoliosis, as the available published clinical data does not support effectiveness.

BILLING/CODING INFORMATION:

The following codes may be used to describe neuromuscular electrical stimulators:

HCPCS Coding:

E0731

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

E0744

Neuromuscular stimulator for scoliosis (non-covered)

E0745

Neuromuscular stimulator, electronic shock unit

E0770

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

Note: E0731 used with an FDA-approved NMES device that meets criteria, is covered when prescribed by a physician.

ICD-9 Diagnoses Codes That Support Medical Necessity:

728.2

Muscular wasting and disuse atrophy, not elsewhere classified

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

M62.50

Muscle wasting and atrophy, not elsewhere classified, unspecified site

M62.511 – M62.519

Muscle wasting and atrophy, shoulder

M62.521 – M62.529

Muscle wasting and atrophy, upper arm

M62.531 – M62.539

Muscle wasting and atrophy, forearm

M62.541 – M62.549

Muscle wasting and atrophy, hand

M62.551 – M62.559

Muscle wasting and atrophy, thigh

M62.561 – M62.569

Muscle wasting and atrophy, lower leg

M62.571 – M62.579

Muscle wasting and atrophy, ankle and foot

M62.58

Muscle wasting and atrophy, not elsewhere classified, other site

M62.59

Muscle wasting and atrophy, not elsewhere classified, multiple sites

REIMBURSEMENT INFORMATION:

Supplies for Rented NMES Units

The reimbursement for supplies used with a rented NMES (E0745) unit is included in the rental allowance and includes the following:

Supplies for Purchased NMES Units

If the NMES unit (E0745) is purchased, the initial allowance includes lead wires and one month’s supply of electrodes, conductive paste or gel (if needed), and batteries.

A separate allowance is made for medically necessary replacement supplies used with a purchased NMES unit. Reimbursement for NMES supplies is limited to one unit of A4595 per month.

Replacement of damaged lead wires (A4557) is rarely medically necessary more frequently that every 12 months.

Reimbursement for A4595 includes the following:

Other Supplies

No separate or additional reimbursement is made for the following supply items:

Sequential stimulators (e.g., RS-4i) are considered deluxe items that are reimbursed as TENS units; no additional allowance is made for these devices, above the allowance for a TENS unit.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline revised date: Neuromuscular Electrical Stimulation (160.12) and Supplies Used in the Delivery of Transcutaneous Electrical Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) (160.13) located at cgsmedicare.com.

DEFINITIONS:

Atrophy: wasting away; decreased size of a body party, organ, tissue, and cell.

Neuromuscular: pertaining to the nerves and muscles.

RELATED GUIDELINES:

Functional Neuromuscular Stimulation, 09-E0000-54
Threshold Therapeutic Electrical Stimulation (TES) as a Treatment of Motor Disorders, 09-E0000-34

OTHER:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

NOTE: Refer to MCG 09-E0000-54, Functional Neuromuscular Stimulation for information regarding Bioness L300™.

REFERENCES:

  1. American Physical Therapy Association (APTA) Guidelines; Defining Physical Therapy In State Practice Acts BOD G03-00-16-38.
  2. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination for Neuromuscular Electrical Stimulation, Publication 100-3, Section 160.12, (10/01/06).
  3. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination for Supplies Used in the Delivery of Transcutaneous Electrical Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES), Publication 100-3, Section 160.13, (07/14/98).
  4. Church C, Price C, Pandyan AD, Huntley S, Curless R, Rodgers H. Randomized controlled trial to evaluate the effect of surface neuromuscular electrical stimulation to the shoulder after acute stroke. Comment in: Stroke. 2007 Aug; 38(8): e71; author reply e72-3.
  5. ClinicalTrials.gov. Early Neuromuscular Electrical Stimulation for Quadriceps Muscle Activation Deficits Following Total Knee Replacement. NCT00800254.
  6. ClinicalTrials.gov. Randomized, Controlled Study to Investigate the Effect of Neuromuscular Electrical Stimulation (NMES) on Muscle Metabolism of Abdominal Surgical Patients. NCT00635440.
  7. ClinicalTrials.gov. The Effect of Neuromuscular Electrical Stimulation (NMES). NCT00765739.
  8. HAYES Directory of Medical Technology. Neuromuscular Elexctrical Stimulation for Muscle Rehabilitation, (01/03/08).
  9. HAYES Search and Summary Report. Neuromuscular Electrical Stimulation using the Ortho DX™ (Rehabilicare Inc.) for Postoperative Knee Rehabilitation, (08/26/06).
  10. Kerr C, McDowell B, Cosgrove A, Walsh D, Bradbury I, McDonough S. Electrical stimulation in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2006 Nov; 48(11): 870-6. Comment in: Dev Med Child Neurol. 2006 Nov; 48(11): 868.
  11. Man IO, Morrissey MC, Cywinski JK. Effect of neuromuscular electrical stimulation on ankle swelling in the early period after ankle sprain.Phys Ther. 2007 Jan; 87(1): 53-65. Epub 2006 Dec 19. Stroke. 2006 Dec; 37(12): 2995-3001. Epub 2006 Oct 19.
  12. Monaghan B, Caulfield B,O’Math├║naDP. Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007177. DOI: 10.1002/14651858.CD007177.
  13. National Guideline Clearinghouse. Clinical practice guidelines for electrical stimulation. Developed by the Ottawa Panel Evidence-Based Clinical Practice Guidelines Development Group. 2006.
  14. Peterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstar A, Newcomb W, Snyder-Mackler L. Improved Functioning From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort. Arthritis Care & Research, February 2009.
  15. St. Anthony’s ICD-9-CM Code Book (current edition).
  16. U.S. Food and Drug Administration (FDA) 510(k) Summary K023347 (12/06/02) and K070425 (06/11/07).
  17. Verweij LM, Van Schoor NM, Deeg JH, Dekker J, Visser M. Physical Activity and Incident Clinical Knee Osteoarthritis in Older Adults. Arthritis Care & Research, February 2009.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/22/09.

GUIDELINE UPDATE INFORMATION:

09/15/02

Reformatted Medical Coverage Guideline.

10/15/03

Scheduled review; no change in coverage statement.

07/15/06

Unscheduled review with revisions consisting of adding reimbursement information for supplies.

10/15/07

Reviewed and reformatted guideline; updated references.

11/15/08

Scheduled review; no change in position statement; updated references.

01/01/09

Annual HCPCS coding update: added E0770.

11/15/09

Scheduled review; position statement unchanged; references updated.

01/01/10

Annual HCPCS coding update: removed A4365.

10/15/10

Revisions; related ICD-10 codes added; formatting changes.

07/15/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

09/15/14

Revision: added E0731 to Billing/Coding Information section.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

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Date Printed: July 3, 2015: 09:38 PM