NMES involves the use of a device which 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 stimulates the muscle when the patient is in a resting state to treat muscle atrophy. The second type is used to enhance functional activity of neurologically impaired patients.

Treatment of Muscle Atrophy
Coverage of NMES to treat muscle atrophy (E0745) is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).

Use for Walking in Patients with Spinal Cord Injury (SCI)
The type of NMES that is used to enhance the ability to walk of SCI patients (e.g., Parastep)(E0764) is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program.

The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.

Coverage for NMES/FES for walking will be covered in SCI patients with all of the following characteristics:

1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve);
2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently;
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation sufficient for muscle contraction;
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking;
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;
6. Persons that can demonstrate hand and finger function to manipulate controls;
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery;
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and
9. Persons who have demonstrated a willingness to use the device long-term.

NMES/FES for walking will not be covered in SCI patients with any of the following:

1. Persons with cardiac pacemakers (V45.01, V45.89, V53.31) or cardiac defibrillators (V45.00, V45.02, V45.09);
2. Severe scoliosis or severe osteoporosis (733.00-733.09, 736.89, 736.9, 737.30-737.39, 737.40, 737.43, 738.4, 738.5, 754.2);
3. Skin disease or cancer at area of stimulation;
4. Irreversible contracture (736.00-736.09, 736.30-736.39, 736.6, 736.70-736.79, 736.81, 736.89); or
5. Autonomic dysreflexia (337.3).

The only settings where therapists with the sufficient skills to provide these services are employed are inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities. The physical therapy necessary to perform this training must be part of a one-on-one training program.

Additional therapy after the purchase of the DME would be limited by our general policies in coverage of skilled physical therapy.

Neuromuscular electrical stimulation (NMES) reported for any other condition will be denied as not medically necessary. Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Diagnosis code 344.1 must be present for payment to be made for NMES that is used to enhance the ability to walk of SCI patients (E0764). However, while paraplegia of both lower limbs is a necessary condition for coverage, the nine criteria listed on this policy are also required.

CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.12

Transmittal AB-02-156, CR 2314