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Neuromuscular Electrical Stimulation (NMES) involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Also known as an electronic shock unit, this therapeutic electrical stimulator is designed for home use. The NMES causes muscles to contract as a form of exercise or physical therapy.
As an adjunct to traditional physical therapy, NMES of healthy muscle is intended to strengthen or maintain muscle mass during or following periods of enforced inactivity, maintain or gain range of motion, facilitate voluntary muscle control, and temporaily reduce spasticity. This is often the result of chronic neuromuscular disorders such as cerebral palsy, spina bifida, club foot and some nonprogressive myopathies.
POLICYNeuromuscular Electrical Stimulation (NMES) or electronic shock unit is covered only where nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves and it is used for treatment of the following:
High voltage pulsed current, also called electrogalvanic stimulation, may also be covered to reduce swelling and control pain. However, its use in the treatment of wounds and ulcers is investigational.
Neuromuscular Electrical Stimulation (NMES) is considered investigational for treatment of the following:
Neuromuscular stimulation may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be used with appropriate therapeutic procedures (for example; 97110) to effect continued improvement. (A limited number of visits without a therapeutic procedure may be medically necessary for treatment of muscle spasm.)
Standard treatment is 3 to 4 sessions a week for one month when used as adjunctive therapy or muscle retraining.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table.
SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. 204-213.
Guidelines for Cognitive Rehabilitation, NeuroRehabilitation, August, 1992, pp. 62-67.
Published Trials of Nonmedical and Noninvasive Therapies for Hip and Knee Osteoarthritis, Annals of Internal Medicine, Physical Therapy, vol. 121, Number 2, May 1990, pp. 133-140.
Pulsed Current, Intermittent Pneumatic Compression, and Placebo Treatments, Physical Therapy, vol. 70, number 5, May 1990, pp. 279-286.
Physical Medicine and Rehabilitation Practice Guidelines, Section DeFisiatria, Association Medica De Puerto Rico, First Edition, copyright 1995.
American Physical Therapy Association
American Occupational Therapy Association
Board Certified Physical Medicine and Rehabilitation Physicians
Licensed Physical Therapist Consultants
Licensed Occupational Therapist Consultants
Carrier Medical Directors PM&R Clinic Workgroup
Hayes Medical Technology Directory
Health Care Financing Administration Specialists and Consultant
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.