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Coverage criteria policies

Functional electrical stimulation (FES) in the home

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not applicable for FES in the home because it is considered investigational/experimental. The provider and facility will be liable for payment unless:

  1. the provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  2. the member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  3. the claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

Functional Electrical Stimulation (FES) in the home is not covered, as it is considered investigational/experimental.

The scope of this policy is limited to the home use of FES. FES may be covered when used as part of a facility based rehabilitative physical therapy program, when the condition is acute and significant improvement is expected within a predictable period of time (generally within 60 days) as a result of therapy. Please see related content at the right for link to the Physical & occupational therapy - rehabilitation coverage policy for details.

Indications that are not covered (included for informational purposes only, list may not be all inclusive)

  1. Upper extremity FES devices such as the NESS H200 and Handmaster (made by Bioness) are not covered for in-home use, either rental or purchase.
  2. Lower extremity FES devices such as the Parastep System, NESS L300, WalkAide, Odstock Dropped Foot Stimulator are not covered for in-home use, either rental or purchase.
  3. In-home stationary exercise FES devices such as the RT300 cycle ergometer (Restorative Therapies, Inc.) and ERGYS I (Therapeutic Alliance, Inc.) are not covered as they are considered to be exercise equipment.
  4. FES therapy for the purpose of maintaining physical condition or maintenance therapy for a chronic condition is not covered (both in-home use and as part of a facility based rehabilitative PT program). Examples include, but are not limited to:
    1. prevention of lower extremity atrophy
    2. to assist maintenance of cardiovascular conditioning/endurance
    3. prevention of decubiti OR bladder infections OR pulmonary complications
    4. to maintain bone mineralization
    5. to maintain or increase range of motion
    6. correction of gait disorders
    7. to relax muscle spasms

Definitions

Functional Electrical Stimulation (FES) is used to enhance functional activity in neurologically impaired patients. These devices send electrical impulses to activate paralyzed or weak muscles in precise sequence, in an attempt to stimulate a muscle disabled after a neurological event such as spinal cord injury, multiple sclerosis, stroke, etc.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

E0764

Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program

E0770

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

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Barrett, C. L., Mann, G. E., Taylor, P. N., & Strike, P. (2009). A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis. Multiple Sclerosis, (15), 493–504. DOI: 10.1177/1352458508101320.
  2. ECRI Institute. (2016). Functional electrical stimulation for rehabilitation of children with central nervous system disorders or injuries causing muscle paralysis. Plymouth Meeting, PA: ECRI Institute.
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Functional Electrical Stimulation (FES) for Upper Extremity Rehabilitation Post Stroke. Lansdale, PA: Hayes, Inc.; July, 2009. Archived August, 2014.
  4. Hayes, Inc. Hayes Medical Technology Directory Report. Functional Electrical Stimulation for Rehabilitation Following Spinal Cord Injury. Lansdale, PA: Hayes, Inc.; November, 2017.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Neuromuscular Electrical Stimulation for Rehabilitation in Patients with Cerebral Palsy. Lansdale, PA: Hayes, Inc.; December, 2010. Archived January, 2016.
  6. Hayes, Inc. Hayes Health Technology Brief. Functional Electrical Stimulation (FES) for Treatment of Foot Drop in Multiple Sclerosis Patients. Lansdale, PA: Hayes, Inc.; July, 2015. Reviewed June, 2017.
  7. Kerr, C., McDowell, B., Cosgrove, A., Walsh, D., Bradbury, I., & McDonough, S. (2006). Electrical stimulation in cerebral palsy: a randomized controlled trial. Developmental Medicine & Child Neurology, 48, 870–876.
  8. Kluding, P. M., Dunning, K., O’Dell, M. W., Wu, S. S., Ginosian, J., Feld, J., & McBride, K. (2013). Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke, (44), 1660-1669.
  9. Patterson, M. C. Management and prognosis of cerebral palsy. In: UpToDate, Bridgemohan, C., & Armsby, C. (Eds), UpToDate, Waltham, MA. (Accessed on March 1, 2018.)
  10. Pomeroy, V. M., King, L. M., Pollock, A., Baily-Hallam, A., & Langhorne, P. (2006). Electrostimulation for promoting recovery of movement or functional ability after stroke: systematic review and meta-analysis. Stroke, 37, 2441-2442. doi: 10.1161/01.STR.0000236634.26819.cc
  11. Springer, S., & Khamis, S. (2017). Effects of functional electrical stimulation on gait in people with multiple sclerosis – a systematic review. Multiple Sclerosis and Related Disorders, 13, 4–12. http://dx.doi.org/10.1016/j.msard.2017.01.010.
  12. van Peppen, R. P. (2008). Towards evidence-based physiotherapy for patients with stroke. Utrecht University.
  13. van Swigchem, R., Vloothuis, J., den Boer, J., Weerdesteyn, V., & Geurts, A. C. (2010). Is transcutaneous 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. Journal of Rehabilitation Medicine, 42(2), 117-21.

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Policy activity

  • 03/03/2011 - Date of origin
  • 03/01/2018 - Effective date
Review date
  • 03/2018

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