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Coverage criteria policies

Functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES) & other electrical stimulation devices - Minnesota Health Care Programs

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 required for neuromuscular electrical stimulators (NMES) and functional electrical stimulators (FES).

Prior authorization is not applicable for electrical stimulation devices which are considered investigational/experimental. The provider and facility will be liable for payment unless:

  • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  • 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

NMES and FES are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Neuromuscular electrical stimulators
    1. Neuromuscular stimulators are covered for treatment of disuse muscle atrophy where nerve supply to the muscle is intact and where there is a non-neurological reason for the disuse atrophy.
    2. Neuromuscular stimulators are covered for members with juvenile or adolescent single or double major idiopathic scoliosis, who are at risk for curve progression and whose curvature is between 25 and 40 degrees. Neuromuscular stimulators may be covered for members in the 20 to 25 degree range if there is a documented progression of curvature of at least 5 degrees in the preceding six months.
  2. Functional electrical stimulators
    1. Upper extremity functional electrical stimulators (e.g. NESS H200, Handmaster) are covered when documented improvement has been shown in the supervised rehabilitation setting for members with upper limb paralysis due to cervical spinal cord injury or chronic upper extremity paresis due to stroke.

Indications that are not covered

  1. Neuromuscular stimulators for scoliosis are not medically necessary for members with curvature is less than 20 degrees.
  2. Use of an upper extremity functional electrical stimulator in the home setting for indications other than specified above is considered investigative.
  3. Use of a lower extremity functional electrical stimulator in the home setting (for example, ParaStep, NESS L300, WalkAide) is considered investigative.
  4. Use of functional electrical stimulators designed as ergometers (for example, StimMaster, ERGYS, REGYS, RT300) is considered investigative and not the prevailing standard of care for any condition.
  5. Interferential current simulators (e.g. RS-4i) for use in the home are considered investigative for all indications.
  6. Cranial electrotherapy stimulation (e.g. Alpha-Stim, CES Ultra) is considered investigative for all indications.
  7. Electrical or electromagnetic stimulation for the treatment of osteoarthritis or rheumatoid arthritis (e.g. BioniCare Bio-1000) is considered investigative.
  8. Use of neurofeedback/EEG biofeedback devices in the home is considered investigative.
  9. Electronic salivary reflex stimulator is considered investigative, not the standard of care.
  10. Non-invasive nerve stimulators for treatment of nausea (e.g. ReliefBand, PrimaBella) are considered investigative.
  11. Use of the Sympathetic Therapy System (e.g. Dynatron STS) is considered investigative for all indications.
  12. Use of electroceutical/bioelectric nerve block is considered investigative for all indications.

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

    E0744

    Neuromuscular stimulator for scoliosis

    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

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 800-233-9645.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual, Equipment and Supplies, Electrical Stimulation Devices. (Revised 01-11-2017.)

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Policy activity

  • 08/07/2012 - Date of origin
  • 03/01/2018 - Effective date
Review date
  • 03/2018

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