Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-30
Topic: Functional Electrical Stimulation (FES)
Effective Date: June 1, 2009
Issued Date: May 17, 2010
Date Last Reviewed: 03/2009

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.

Coverage for prosthetics and orthotics is determined according to individual or group customer benefits.


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

Nightingale EJ, Raymond J, Middleton JW, Crosbie J, Davis GM.  Benefits of FES gait in a spinal cord injured population.  Spinal Cord.  2007 Oct;45(10):646057.

Ng MF, Tong RK, Li LS.  A pilot study of randomized clinical controlled trial of gait training in subacute stroke patients with partial body-weight support electromechanical gait trainer and functional electrical stimulation:  six-month follow-up.   Stroke.  2008 Jan;39(1):154-60.

Laufer Y, Hausdorff JM, Ring H. Effects of a foot drop neuroprosthesis on functional abilities, social participation and gait velocity.  AM J Phys Med Rehabil.  2009 Jan;88(1):14-20.

Seifart A, Unger M, Burger M.  The effect of lower limb functional electrical stimulation on gait of children with cerebral palsy.  Pediatr Phys Ther. 2009 Spring;21(1):23-30.

Mangold S, Schuster C, Keller T, Zimmermann-Schlatter A, Ettlin T.  Motor training of upper extremity with functional electrical stimulation in early stroke rehabilitation.  Neurorehabil Neural Repair. 2009 Feb;2392:184-90.

Hausdorff JM, Ring H.  Effects of a new radio frequency-controlled neuroprostheses on gait symmetry and rhythmicity in patients with chronic hemiparesis.  Am J Phys Med Rehabil.  2008 Jan;87(1):4-13.

Weingarden, Harold P, MD, Hausdorff, Jeffrey M, PhD.  FES neuroprosthesis versus an ankle foot orthosis:  the effect on gait stability and symmetry.  Physiotherapy 2007:93 (Supplement 1):  S359.

Alon, Gad, MD, Hausdorff Jeffery, MA, Ring, Haim.  One year follow-up of patients who are using the NESS L300 neuroprosthesis:  effects on gait performance.  Stroke, Vol. 39 No.2 February 2008.

Alon Gad, PhD, PT; Levitt, Alan F, MD; McCarthy Patricia A, OTR.  Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study.   Neurorehabilitation and neural repair.  Volume 21 Number 3 pp. 207-215, 2007.

View Previous Versions

[Version 004 of O-30]
[Version 003 of O-30]
[Version 002 of O-30]
[Version 001 of O-30]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

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.