Other Services
Chapter 8
Section 5.2
Neuromuscular
Electrical Stimulation (NMES) Devices
Issue Date: July 8, 1998
Revision:
1.0 DESCRIPTION
NMES devices contain a power
supply (general rechargeable batteries), a signal generator, a control
circuit, a modulating circuit and output circuit, and electrodes.
Electrodes may be superficial, percutaneous, or implanted. Functional
electrical stimulation is artificial electrical stimulation of muscles
to produce movements such as standing, walking, and grasping. NMES
is used to facilitate voluntary motor control and temporarily reduce spasticity
in patients suffering from spinal cord injury, cerebral palsy, or
other upper motor neuron disorders. NMES units are considered class
II devices.
2.0 POLICY
2.1 When used
in a program approved by the attending physician, NMES may be cost-shared
for the following indications:
2.1.1 For prevention
and/or treatment of disuse atrophy, where nerve supply to the muscle
is intact, due to a condition such as:
• Recent hip surgery until the
patient begins physical therapy; or
• Prolonged (greater than 12
weeks) casting or splinting of a joint; or
• Contractures as a result of
scarring of soft tissue from burns.
2.1.2 For spinal cord injury and
other motor neuron disorders (such as cerebral palsy) where nerve
supply to the muscle is intact; or
2.1.3 For idiopathic
scoliosis in pediatric and adolescent patients.
2.2 The device is approved by the
United States (US) Food and Drug Administration (FDA) for commercial marketing
for a specific application and must be medically necessary for the
treatment of the condition for which the device is intended to be
used.
2.3 NMES devices approved by FDA
(e.g., Parastep I System, Respond II) may be cost-shared on an inpatient or
outpatient basis.
2.4 For other
conditions, the medical necessity of the equipment is required.
3.0 EXCLUSIONS
3.1 Neuromuscular
stimulators used by spinal cord-injured patients who have epilepsy,
cognitive deficiencies, osteoporosis, spasticity or other conditions
that could interfere with its safe use are excluded.
3.2 Claims for neuromuscular stimulators
used on denervated muscle should be denied as unproven medical treatment
or procedure.
3.3 Claims for neuromuscular stimulators
used as part of an exercise program of healthy individuals (i.e., athletes)
cannot be considered for cost-sharing as this is not medically necessary
service and supply required in the diagnosis and treatment of an
illness or injury.
3.4 The treatment
of scoliosis with implanted electrical muscle stimulation is considered
unproven and is not a covered benefit.
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