CAM 014

Neuromuscular Electrical Stimulation (NMES)

Category:Durable Medical Equipment   Last Reviewed:September 2018
Department(s):Medical Affairs   Next Review:September 2019
Original Date:March 2007    

Description:
Neuromuscular electrical stimulation (NMES), also known as therapeutic (or threshold) electrical stimulation (TES) is a form of electrical stimulation that attempts to strengthen muscles weakened by disuse. TES uses sub-contraction stimulus to promote muscle growth. In an individual with disuse atrophy, contracting muscles use the strongest fibers; therefore weakened muscles do not respond and deteriorate further. NMES is used at night during sleep and is purported to increase blood flow to the muscles in which fibers are atropied. NMES can also be used in the outpatient setting as an adjunct therapy to treat muscle atrophy.

NMES has been used for individuals who have joint mobility problems, such as contractures, circulation inadequacies, disuse atrophy, spasticity (tone abnormalities) and gail abnormalities such as foot drop. NMES has also been used for orthopedic rehabilitation in individuals, who have musculoskeletal dysfunctions (e.g., disuse weakness, joint restrictions, edema and spasms). This therapy is used in conjunction with physical and occupational therapies to strengthen muscle tone and improve functional abilities..

Policy:
FDA approved neuromuscular stimulator devices may be considered MEDICALLY NECESSARY when prescribed for disuse muscular atrophy from prolonged immobilization and that is present in the setting of an intact nerve supply to the muscle, including brain, spinal cord and peripheral nerves. 

A neuromuscular stimulator garment is considered NOT MEDICALLY NECESSARY.  

Neuromuscular stimulation is considered NOT MEDICALLY NECESSARY for: 

  • Prevention of muscle atrophy, e.g., following an orthopedic procedure;
  • Treatment of pain for various musculoskeletal conditions, including, but not limited to patellofemoral syndrome, spinal stenosis, lumbago, muscle strains/sprains;
  • As a technique to increase circulation. 

Contraindications:
NMES/FES is contraindicated for members with SCI with ANY of the following:
 

  1. Cardiac pacemakers; OR,
  2. Severe scoliosis; OR,
  3. Severe osteoporosis; OR,
  4. Skin disease or cancer at area of stimulation; OR,
  5. Irreversible contracture; OR,
  6. Autonomic dysreflexia.

Rationale:
In 2010 Monaghan and colleagues reviewd available literature assessing the effectiveness of NMES in regards to quadricep strength before and after total knee replacement. The studies had no significant differences reported for maximum voluntary isometric torque or endurance between the NMES group and the control group.  In on study there was a difference in quadriceps muscle activation in the group with NMES & exercise from the control group utilizing exercise alone.  This difference was much more significant at 6 weeks than at 12 weeks.  Further analysis was not possible related to the absence of raw data scores.  The authors concluded that the available studies preclude any conclusions regarding NMES quadricps strenthening pre and post op total knee replacement.

In 2010, a study was conducted evaluating the effect of NMES on quadriceps muscle strength and activiation in women with mild and moderate osteoarthritis by Palmieri-Smith and colleagues.  The was a treatment and a non-treatment group.  The treatment group received NMES 3 times a week for 4 weeks.  At the conclusion of the study, no improvement was noted in the treatment group. 

In 2012 results of a post TKA NMES quadriceps study were published.  This study conducted by Stevens-Lapsley and colleagues initiated NMES 48 hours post TKA in addition to standard rehabilitation.  Subjects were randomly assigned to either NMES and standard rehabilitation or standard rehabilitation.  Significant improvement in the NMES group was noted in quadriceps and hamstring strength at 3.5 weeks post op.  There was also improved functional performance, knee extension and active range of motion noted.   Authors concluded that early addition of NMES reduced loss of quadricpes muscle strength and improved functional performance following TKA.  Results persisted through 52 weeks post op, but, were most notable in the first post operative month. As this was a small study with volumes not matched in both arms of the study, the authors stated further research is warranted regarding early intervention with NMES after TKA. 

Numerous clinical trials are currently on going regarding NMES. They include studies related to multiple sclerosis, cerebral palsy, hemiparetic patients and ICU associated weakness.  Several studies have recently been completed with data not yet published. 

Definitions:
TENS: Transcutaneous Electrical Nerve stimulator is a device used to treat chronic intractable pain, and pain associated with active or post-traumatic injury unresponsive to other standard pain therapies. The device is applied to the surface of the skin at the site of the pain. It consists of an electrical pulse generator, usually battery operated, connected by a wire to two or more electrodes. A programmable stimulator may be programmed in advance to stimulate at regular times or upon demand by the use of a hand held magnet over the stimulator. (Neuro Cybernetic Prosthesis System)
 

MNS: Microcurrent Nerve Stimulator works on the same principal as TENS by delivering microcurrent instead of regular current. 

PENS: Percutaneous Nerve Stimulator is similar to TENS, with the exception that instead of electrodes attached to the skin near the pain area, in PENS, a needle is inserted into the pain site. 

PNT:  Percutaneous neuromodulation therapy is a variant of PENS in which up to 10 fine filament electrodes are temporarily placed at specific anatomical landmarks in the back.  Treatment regimens consist of 30-minute sessions, once or twice a week for 8 to 10 sessions. 

VNS: Implanted vagus nerve stimulation (VNS) devices have been used to treat patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed. Surgery for implantation of the VNS device is done with the patient under either general anesthesia or regional cervical block. Since right vagus nerve stimulation produces bradycardia, implantation is limited to left-sided unilateral implantations. Two spiral electrodes are implanted around the left vagus nerve within the carotid sheath, which are connected to an infraclavicular generator pack. A programmable stimulator may be programmed in advance to stimulate at regular times or upon demand by the use of a hand held magnet over the stimulator. ( Neuro Cybernetic Prosthesis System) 

FNS: Functional Neuromuscular Stimulation attempts to replace stimuli from destroyed nerve pathways with electrical stimulation to the muscles. It is presumed that electric stimulation enables the spinal cord injured patient to stand or walk independently, or to maintain healthy muscle tone and strength. 

NMES: Neuromuscular Electric Stimulator for disuse atrophy.  NMES involves the use of a device that transmits an electrical impulse to activate muscle groups by way of electrodes.  There are two broad categories of NMES. One type of device stimulates the muscle when the patient is in a resting state to treat muscle atrophy.  The second type is used to enhance functional activity of neurologically impaired patients. 

Spinal Cord Stimulation for Chronic Pain:  Electrodes are implanted in the epidural space to stimulate the dorsal column and treat chronic pain. 

DBS: Deep Brain Stimulation of the thalamus has been used as an alternative to permanent neuroablative procedures such as thalamotomy and pallidotomy for control of essential tremor, and tremors associated with Parkinson's disease.  It involves stereotactic placement of an electrode into the brain, which is attached to a temporary transcutaneous cable for short-term stimulation to validate treatment effectiveness.  Several days later a permanent subcutaneous programmable stimulator is implanted.  DBS of the globus pallidus and subthalamic nucleus has also been investigated for other symptoms of Parkinson's disease such as rigidity, bradykinesia or akinesia.  DBS is also FDA approved for the treatment of dystonia. 

H-Wave® Electric Stimulation: This device is used for the treatment of pain related to a variety of etiologies. This is also used for wound healing. 

Sensory Stimulation for Coma Patients: Sensory stimulation is intended to enhance awakening and rehabilitative potential of coma patients.  Treatment may be delivered in the hospital, the patient's home, or a nursing home by professionals including nurses, occupational therapist, physical therapist, speech language therapist and even by a trained family member. 

TES: Threshold Electric Stimulator as a treatment of motor disorders. Low intensity electrical stimulation is used to target spastic muscles during sleep at home. Although the exact mechanism of action is not known, it is presumed that it may increase muscle strength and joint mobility leading to improved voluntary motor function. This is used in children with spastic paraplegia related to cerebral palsy and also in those with other motor disorders, such as spina bifida. 

Sympathetic therapy as a treatment of chronic pain (i.e. Dynatron STS): Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves that is designed to stimulate the sympathetic nervous system in an effort to 'normalize' the autonomic nervous system and alleviate chronic pain.  Sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain. 

Interferential current stimulation (IFC) is a type of electrical current treatment that uses paired electrodes of two independent medium-frequency alternating currents. The electrodes are arranged on the skin so the current flowing between each pair intersects at the underlying target. IFC has been investigated as a technique to reduce pain, improve range of motion, or promote local healing. 

LymphavisionTM is an electrical stimulation device that stimulates smooth muscles thereby promoting lymphatic flow. It is described as a treatment for such conditions as diabetic foot syndrome and trophic ulcers, and prevention of deep vein thrombosis. 

TEJS: Transcutaneous electrical joint stimulation is the application of a signal-specific electrical current to the joint tissue to relive the signs and symptoms of osteoarthritis of the knee. Two electrode patches are worn for six to ten hours a day, preferably while the patient is sleeping. TEJS has been indicated as adjunctive therapy for patients who have failed NSAIDS, those with moderate to severe disease despite best medical therapy, and those with severe disease who are not surgical candidates for reasons such as morbid obesity and inappropriate age. 

PES: Pulsed electrical stimulation is provided by an electronic device that noninvasively delivers a low voltage, monophasic electrical field to the targeted area of pain. It is used to improve functional status and relieve pain related to osteoarthritis and rheumatoid arthritis unresponsive to other standard forms of treatment.

References:

  1. Bax L, Staes F, Verhagen A. Does neuromuscular electrical stimulation strengthen the quadriceps femoris: A systematic review of randomized controlled trials. Sports Med. 2005; 35(3):191-212.
  2. Burnett, T.A., Mann, E.A., Stoklosa, J.B., & Ludlow, C.L. (2003). Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology, 94, 128-134.
  3. Gould N, Donnermeyer D, Gammon GG, et al. Transcutaneous muscle stimulation to retard disuse atrophy after open meniscectomy. Clin Orthop. 1983; 178:190-197.
  4. Hayes Directory. (2008, January 3). Neuromuscular electrical stimulation for muscle rehabilitation. 
  5. Monaghan B, Caulfield B, O'Mathúna DP. Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement. Cochrane Database Syst Rev, 2010; (1):CD007177.
  6. Palmieri-Smith RM, Thomas AC, Karvonen-Gutierrez C, Sowers M. A clinical trial of neuromuscular electrical stimulation in improving quadriceps muscle strength and activation among women with mild and moderate osteoarthritis. Phys Ther. 2010; 90(10):1441-1452.
  7. Stevens-Lapsley JE, Balter JE, Wolfe P, et al. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther. 2012; 92(2):210-226.

Coding Sections

Codes Number Description
CPT 64550 Application of surface (transcutaneous) neurostimulator
  64565 Percutaneous implantation of neurostimulator electrode array; neuromuscular
  64580 Incision for implantation of neurostimulator electrode array; neuromuscular
  97014 Application of a modality to one or more areas; electrical stimulation (unattended)
  97024 Application of a modality to one or more areas; diathermy (e.g., microwave)
  97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
ICD-9 Diagnosis  728.2 Muscular wasting and disuse atrophy, not elsewhere classified (see criteria)
  709.2 Scar conditions and fibrosis of skin
  717.0 - 717.9 Internal derangement of knee
  718.40 - 718.49 Contracture of joint
  906.6 - 906.7 Late effects of burns
  V43.64 Joint replaced by other means, hip
  V43.65 Joint replaced by other means, knee
HCPCS A4556 Electrodes (e.g., apnea monitor), per pair
  A4557 Lead wires (e.g., apnea monitor), per pair
  A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz.
  A4595 Electrical stimulator supplies, 2 leads, per month, (e.g. TENS, NMES)
  E0745 Neuromuscular stimulator, electronic shock unit
  L8680 Implantable neurostimulator electrode, each
  L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator
  L8682 Implantable neurostimulator radiofrequency receiver
  L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
  L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
  L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
  L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
  L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
  L8689 External recharging system for battery (internal) for use with implantable neurostimulator
ICD-10-CM (effective 10/01/15) M62.50  Muscle wasting and atrophy, not elsewhere classified, unspecified site 
ICD-10-PCS (effective 10/01/15)  L90.5  Scar conditions and fibrosis of skin 
  M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified knee 
  M23.219  Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified 
  M23.319  Other meniscus derangements, anterior horn of medial meniscus, unspecified knee 
  M23.239  Derangement of other medial meniscus due to old tear or injury, unspecified knee 
  M23.305  Other meniscus derangements, unspecified medial meniscus, unspecified knee 
  M23.339  Other meniscus derangements, other medial meniscus, unspecified knee 
  M23.009  Cystic meniscus, unspecified meniscus, unspecified knee 
  M23.40  Loose body in knee, unspecified knee 
  M22.40  Chondromalacia patellae, unspecified knee 
  M23.90  Unspecified internal derangement of unspecified knee 
  M24.50  Contracture, unspecified joint 
  M24.519  Contracture, unspecified shoulder 
  M24.539  Contracture, unspecified wrist 
  M24.549  Contracture, unspecified hand 
  M24.559 Contracture, unspecified hip
  M24.569 Contracture, unspecified knee
  M24.573 Contracture, unspecified ankle
  M24.576 Contracture, unspecified foot
  T23.009S Burn of unspecified degree of unspecified hand, unspecified site, sequela
  T23.079S Burn of unspecified degree of unspecified wrist, sequela
  T23.409S Corrosion of unspecified degree of unspecified hand, unspecified site, sequela
  T23.479S Corrosion of unspecified degree of unspecified wrist, sequela
  T22.00XS Burn of unspecified degree of shoulder and upper limb, except wrist and hand, unspecified site, sequela
  T22.40XS Corrosion of unspecified degree of shoulder and upper limb, except wrist and hand, unspecified site, sequela
  T24.009S Burn of unspecified degree of unspecified site of unspecified lower limb, except ankle and foot, sequela
  T24.409S Corrosion of unspecified degree of unspecified site of unspecified lower limb, except ankle and foot, sequela
  Z96.649 Presence of unspecified artificial hip joint
  Z96.659 Presence of unspecified artificial knee joint

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

08/22/2018 

Annual review, no change to policy intent. 

06/13/2018 

correcting a typo on Date Last Reviewed. No other changes made.

06/04/2018 

 Interim review to update policy. Removing the following verbiage:

As a component of post-operative rehabilitation in either of the following settings:  

  • When muscular atrophy is present before an orthopedic intervention (i.e., repair of anterior cruciate ligament). In this setting, neuromuscular stimulation may be initiated immediately in the post-op phase as an adjunct to physical therapy;
  • When muscular atrophy develops in the post-operative period. Individuals meeting this criterion typically are participating in a physical therapy program, but have experienced complications related to the surgery, which preclude successful physical therapy. In this setting, neuromuscular stimulation may be initiated only after the development of muscle atrophy. 

09/07/2017 

Annual review, no change to policy intent. 

09/01/2016 

Annual review, no change to policy intent. 

09/16/2015 

Annual review, no change to policy intent. Added coding.

09/25/2014

Corrected typos.

09/22/2014

Annual review, no changes made.


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