OAR 410-122-0515: Neuromuscular Electrical Stimulator (NMES)

Indications and limitations of coverage and medical appropriateness: The Division may cover a neuromuscular electrical stimulator (NMES) that uses electrodes to transmit an electrical impulse to the skin over selected muscle groups. There are two (2) broad categories of NMES: (1) One type of NMES is for treatment of muscle atrophy; (a) In this category, the NMES device stimulates the muscle when the client is in a resting state to treat muscle atrophy; (b) The Division shall cover this type of NMES to treat muscle atrophy specific to disuse atrophy where nerve supply to the muscle is intact (including brain, spinal cord and peripheral nerves) and to treat 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). (2) The second type of NMES is commonly referred to as functional electrical stimulation (FES). FES devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. (a) In this category, the FES device is used to enhance functional activity of neurologically impaired clients. FES devices used to improve the ability to walk in clients with spinal cord injury (SCI) shall be covered; (b) The Division shall only cover FES for SCI clients for walking, who meet the following criteria: (A) Client has completed at least thirty-two (32) physical therapy sessions, directly performed one-on-one with the physical therapist with the device over a trial period of three (3) months, with the specific goal of using the FES device to achieve walking, not to reverse or retard muscle atrophy; (B) Therapists with the sufficient skills to provide these services are only employed at inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities; (C) The practitioner treating the client for SCI will use this trial period to properly evaluate the person's ability to use the FES frequently and for the long term; and (D) The client meets all of the following characteristics: (i) Intact lower motor units (L1 and below) (both muscle and peripheral nerve); (ii) Muscle and joint stability for weight bearing at upper and lower extremities that demonstrates balance and control to maintain an upright support posture independently; (iii) Demonstrated brisk muscle contraction to NMES and sensory perception of electrical stimulation sufficient for muscle contraction; (iv) High motivation, commitment and cognitive ability to use FES devices for walking; (v) Can transfer independently and demonstrates independent standing tolerance for at least three (3) minutes; (vi) Demonstrated hand and finger function to manipulate controls; (vii) At least six (6) month post recovery spinal cord injury and restorative surgery; (viii) Hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and (ix) Demonstrated willingness to use the device long-term. (3) FES for walking is contraindicated for a SCI client with any of the following: (a) Cardiac pacemaker; (b) Severe scoliosis or severe osteoporosis; (c) Skin disease or cancer at area of stimulation; (d) Irreversible contracture; or (e) Autonomic dysflexia; (4) The requested system or device shall either be approved, registered, or listed as a medical device with the Food and Drug Administration (FDA) and otherwise generally considered to be safe and effective for the intended purpose. (5) Documentation requirements: (a) Submit the following documentation for prior authorization (PA) review: (A) An order from the treating practitioner; (B) Documentation of signs/symptoms/medical condition exhibited by the client that clearly specifies the medical appropriateness and medical necessity for the device; (C) Medical records that corroborate conditions for coverage are met as specified in this rule. (b) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be made available to the Division upon request. (6) Procedure codes: (a) The Medicare Pricing, Data Analysis and Coding contractor is responsible for assisting DMEPOS providers and manufacturers in determining which HCPCS code shall be used to describe DMEPOS items; (b) Refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for appropriate Healthcare Common Procedure Coding System (HCPCS) codes. (c) NMES: (A) E0745, Neuromuscular stimulator, electronic shock unit — Division shall rent — Purchased after no more than 10 months of rental — PA required. (B) A4595, Electrical stimulator supplies, two (2) lead, per month, (e.g. TENS, NMES) — Includes all supplies necessary for the effective use of the device — Division shall purchase; (d) FES: (A) E0764, Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program; — Division shall rent — Purchased after no more than 10 months of rental — PA required. (B) E0770 – Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified — Division shall rent — Purchased after no more than 10 months of rental — PA required. (C) A4595, Electrical stimulator supplies, two (2) lead, per month/one (1) unit (e.g. FES, NMES) — Includes all supplies necessary for the effective use of the device. Not reimbursable with initial purchase. If medically necessary, a maximum of two (2) units per month (4 leads) is allowed.