Coverage of NMES/FES for walking will be limited to SCI (Spinal Cord Injured) 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 of 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 standing independently 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.

Coverage for the use of NMES/FES is limited to patients with SCI for walking who have completed a training program, which consists of physical medicine sessions with the device over a period of three months. The training period 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. These physical medicine sessions are only covered in the following settings: inpatient hospital; outpatient hospital; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities. The physical medicine necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program; this service cannot be done unattended.

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

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

1. presence of 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. irreversible contracture (736.00-736.09, 736.30-736.39, 736.6, 736.70-736.79, 736.81, 736.89);
4. autonomic dysreflexia (337.3); or
5. skin disease or cancer at area of stimulation.

Claims submitted for these devices for conditions other than paraplegia (344.1) or when any of the conditions listed in criteria 1 through 5 are reported will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Diagnosis code 344.1 must be present for payment to be made. However, while paraplegia of both lower limbs is a necessary condition for coverage, the nine criteria listed on this policy are also required.

Coverage is subject to any applicable physical medicine and/or durable medical equipment (DME) limitation in the member's benefit contract.

Description

Neuromuscular electrical stimulation (NMES) involves the use of a device that transmits an electrical impulse to activate 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, which is addressed on this policy, is used to enhance functional activity of neurologically impaired patients. The type of NMES that is used to enhance walking in spinal cord injury (SCI) patients 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.

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.

PRN References

06/2003, Coverage outlined for neuromuscular electrical stimulation devices used for ambulation

MCIM 35-77

Program Memorandum Transmittal AB-02-156, CR 2314