Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-30
Topic: Functional Electrical Stimulation (FES)
Effective Date: January 1, 2009
Issued Date: January 5, 2009
Date Last Reviewed: 12/2008

General Policy Guidelines

Indications and Limitations of Coverage

Functional Electrical Stimulation (FES)

Functional electrical stimulation (FES) devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence.  FES is a type of neuromuscular electrical stimulator (NMES) that is used to enhance the ability to walk in patients with spinal cord injuries or stroke.  FES attempts to replace stimuli from destroyed nerve pathways with computer-controlled sequential electrical stimulation of muscles.

Functional electrical stimulation (FES) is considered investigational for all FES devices except for the Parastep System. 

Please refer to Medical Policy Bulletin E-40 for NMES/FES devices (i.e., Parastep) used by spinal cord injured patients for walking.

Description

Some examples of functional electrical stimulation include the WalkAide System, NESS H200 and Bioness NESS L300.  This is not an all inclusive list. Please see the Glossary for descriptions of these functional electrical stimulation devices.


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.

Procedure Codes

E0770     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Peroneal Nerve Stimulation Versus an Ankle Foot Orthosis for Correction of Footdrop in Stroke; Impact on Functional Ambulation, Neurorehabilitation Neural Repair, September 2006

A Randomized Controlled Trial of Functional Neuromuscular Stimulation in Chronic Stroke Subjects, Stroke 2006; 37(1):172-8

View Previous Versions

[Version 001 of O-30]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary

TermDescription

WalkAide System

The WalkAide is a foot drop stimulator.  WalkAide uses functional electrical stimulation to restore the typical nerve-to-muscle signals in the leg and foot, effectively lifting the foot at the appropriate time during the gait cycle. It is intended to address the lack of ankle dorsiflexion in patients who have sustained damage to upper motor neurons or pathways to the spinal cord.  During the swing phase of gait, the WalkAide System electrically stimulates the appropriate muscles that cause ankle dorsiflexion and may thus improve the patient’s gait.

 

NESS H200

The NESS H200 is a functional electrical stimulation system to elicit finger and thumb extension and flexion.  It is a non-invasive device worn on the forearm and hand that enables patients to perform everyday activities that were previously impossible. The NESS H200 can help the hand open and close, reduce stiffness, increase range of motion and strength, improve circulation, and assist in regaining awareness of an impaired limb. 

 

Bioness NESS L300

The NESS L300 is a functional electrical stimulation system.  It is intended to provide ankle dorsiflexion in individuals with foot drop following an upper motor neuron injury or disease.  It delivers electrical pulses to the Common Peroneal Nerve which controls the movement of the Dorsiflexors, causing them to dorsiflex the foot in the swing phase of gait.




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.