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Date Printed: June 28, 2017: 11:49 PM

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This medical policy (medical coverage guideline) is Copyright 2017, 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 2017 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-E0000-34

Original Effective Date: 11/15/00

Reviewed: 03/24/11

Revised: 11/01/15

Subject: Threshold Therapeutic Electrical Stimulation (TES) as a Treatment of Motor Disorders

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:

Threshold electrical stimulation (TES) is described as the delivery of low-intensity electrical stimulation to target spastic muscles during sleep at home. The stimulation is not intended to cause muscle contraction. Although the mechanism of action is not understood, it is thought that low-intensity stimulation may increase muscle strength and joint mobility, leading to improved voluntary motor function. The technique has been used most extensively in children with spastic diplegia related to cerebral palsy, but also in those with other motor disorders, such as spina bifida.

Devices used for threshold electrical stimulation are classified as “powered muscle stimulators.” As a class, the U.S. Food and Drug Administration (FDA) describes these devices as “an electronically powered device intended for medical purposes that repeatedly contracts muscles by passing electrical currents through electrodes contacting the affected body area.”

POSITION STATEMENT:

Threshold electrical stimulation as a treatment of motor disorders is considered experimental or investigational for ALL applications due to the lack of published literature to support effectiveness on health outcomes.

BILLING/CODING INFORMATION:

CPT/HCPCS Coding:

There is no specific CPT or HCPCS code for reporting threshold electrical stimulation therapy.

However, providers sometime associate TES with routine physical therapy visits over the course of the entire 12-month course of treatment. In addition, the therapy requires the rental or purchase of an electrical stimulation device, which may be inappropriately coded as E0745 (neuromuscular stimulator, electronic shock unit).

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

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 reviewed date: Treatment of Motor Function Disorders with Electric Nerve Stimulation (160.2) located at cms.gov.

DEFINITIONS:

Cerebral palsy: refers to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination, but do not worsen over time; caused by abnormalities in parts of the brain that control muscle movements; majority of children with CP are born with it, although it may not be detected until months or years later (usually before the child reaches age 3 years).

Diplegia: paralysis of corresponding parts (as the legs) on both sides of the body.

Spina bifida: congenital cleft of the spinal column with hernial protrusion of the meninges and sometimes the spinal cord.

RELATED GUIDELINES:

Neuromuscular Electrical Stimulator (NMES), 09-E0000-25

OTHER:

None applicable.

REFERENCES:

  1. Balcom, A. H., Wiatrak, M., Biefeld, T. et al. (1997). Initial experience with home therapeutic electrical stimulation for continence in the myelomeningocele population. Journal of Urology, 158, 1272-6.
  2. Bates, J. A. (1978). Therapeutic electrical stimulation – the transistorized placebo? Electroencephalogr Clin Neurophysiol Suppl, (34), 329-34.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual – Threshold Electrical Stimulation as a Treatment of Motor Disorders - 1.01.19 (02/11/10).
  4. Centers for Medicare & Medicaid Services (CMS); National Coverage Determination for Treatment of Motor Function Disorders with Electric Nerve Stimulation, Publication 100-3, Section 160.2 (04/01/03).
  5. Dali C, Hansen FJ, Pedersen SA, Skov L, Hilden J, Bjornskov I, Strandberg C, Christensen J, Haugsted U, Herbst G, Lyskjaer U. “Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial.” Dev Med Child Neurol. 2002 Jun; 44(6): 364-9.
  6. ECRI Hotline Response, “Uses of Therapeutic Electrical Stimulation” (10/25/06).
  7. Harris, S. R. (1996). How should treatments be critiqued for scientific merit? Physical Therapy, 76(2), 175.
  8. HAYES Medical Technology Directory; Neuromuscular Electrical Stimulation for Muscle Rehabilitation (04/15/03; updated 02/26/07).
  9. 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.
  10. National Institute of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS). Spinal Cord Injury: Emerging Concepts website. Updated 06/22/07 (accessed 06/22/07).
  11. Scianni A, Butler JM, Ada L, Teixeira-Salmela LF. Muscle strengthening is not effective in children and adolescents with cerebral palsy: a systematic review. Aust J Physiother. 2009;55(2):81-7.
  12. Sommerfelt K, Markestad T, Berg K, Saetesdal I. “Therapeutic electrical stimulation in cerebral palsy: a randomized, controlled, crossover trial.” Dev Med Child Neurol. 2001 Sep; 43(9): 609-13.
  13. Van der Linden ML, Hazlewood ME, Aitchison AM, Hillman SJ, Robb JE. “Electrical stimulation of gluteus maximus in children with cerebral palsy: effects on gait characteristics and muscle strength.” Dev Med Child Neurol. 2003 Jun; 45(6): 385-90.
  14. Waugaman, W. A. (1997). Electrical current density model from surface electrodes. Biomedical Science Instruments, 34, 131-6.
  15. Woodworth, B. (1993). Defying the odds: therapeutic electrical stimulation can be useful in treating various forms of neuromuscular disorders. Independent Living, 8(4), 32.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/24/11.

GUIDELINE UPDATE INFORMATION:

11/15/00

New Medical Coverage Guideline.

12/15/01

Annual review for investigational – no change – references added.

12/15/02

Annual review for investigational – no change – reference added.

11/15/03

Reviewed; no change (investigational).

10/15/04

Scheduled review; no change in coverage statement.

11/15/05

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

11/15/06

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

08/15/07

Scheduled review; reformatted guideline; updated references.

11/15/08

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

11/15/09

Scheduled review; position statement unchanged; references updated.

04/15/11

Review; position statement unchanged; references updated.

05/15/14

Revision; Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 28, 2017: 11:49 PM