mp-157 - Medical Policies - Alabama
Threshold Electrical Stimulation as a Treatment of Motor Disorders
Policy Number: MP-157
Latest Review Date: January 2021
Category: Durable Medical Equipment (DME)
Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.
Threshold Electrical Stimulation (TES), as a treatment of motor disorders including but not limited to cerebral palsy, spina bifida, idiopathic scoliosis, or brachial plexus injuries, is considered not medically necessary.
DESCRIPTION OF PROCEDURE OR SERVICE:
Threshold electrical stimulation is provided by a small electrical generator, lead wires, and surface electrodes that are placed over the targeted muscles. The intensity of the stimulation is set at the sensory threshold and does not cause a muscle contraction.
Threshold electrical stimulation is described as the delivery of low intensity electrical stimulation to target spastic muscles during sleep at home. The stimulation is not intended to cause muscle contraction. Although the mechanism of action is not understood, it is thought that low intensity stimulation may increase muscle strength and joint mobility, leading to improved voluntary motor function. The technique has been used most extensively in children with spastic diplegia related to cerebral palsy (CP), where the patient may have disuse atrophy. It has also been used with other motor disorders, such as spina bifida, brachial plexus injuries, central nervous system injuries, post-polio syndrome, and idiopathic scoliosis.
The TES device is a small battery powered unit with two lead wires, and each of these has two electrodes attached at the ends. These electrodes are attached to certain areas of the skin. The technique involves the administration of small electrical stimuli to the skin overlying selected “weakened” muscles that are usually opposite the spastic muscles. TES is thought to work by increasing local blood flow, and along with the nightly secretion of trophic hormones, to enlarge the atrophic muscles and improve motor function.
The most recent literature search was performed through January 2021.
Summary of Evidence:
Many studies were identified in the peer literature review and none of them demonstrating effectiveness. Validation of therapeutic electrical stimulation requires randomized, controlled studies that can isolate the contribution of the electrical stimulation from other components of therapy. Physical therapy is an important component of the treatment of cerebral palsy and other motor disorders. Therefore, trials of threshold electrical stimulation ideally should include standardized regimens of physical therapy. Randomized studies using sham devices are preferred to control for any possible placebo effect. Many randomized trials have failed to show clinically significant improvement in muscle strength or function utilizing Threshold Electrical Stimulation (TES) although alternative medicine is often used in motor disorders.
PRACTICE GUIDELINES AND POSITION STATEMENTS:
National Institute of Neurological Disorders and Stroke
Many children and adolescents with cerebral palsy use some form of complementary or alternative medicine. Controlled clinical trials involving some of the therapies have been inconclusive or showed no benefit, and the therapies have not been accepted in mainstream clinical practice. Although there are anecdotal reports of some benefit in some children with cerebral palsy, these therapies have not been approved by the U.S. food and Drug Administration for the treatment of cerebral palsy. Such therapies include hyperbaric oxygen therapy, special clothing worn during resistance exercise training, certain forms of electrical stimulation, assisting children in completing certain motions several times a day, and specialized learning strategies.
Threshold Electrical Stimulation (TES), cerebral palsy, spina bifida, idiopathic scoliosis, brachial plexus injuries
APPROVED BY GOVERNING BODIES:
Devices used for threshold electrical stimulation are classified as “powered muscle stimulators”. As a class, the FDA describes these devices as “an electronically powered device intended for medical purposes that repeatedly contracts muscles by passing electrical currents through electrodes contacting the affected body area”.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved. Will be reviewed for medical necessity.
Neuromuscular stimulator, electronic shock unit
This code may also be used for other neuromuscular stimulators
- Barkoudah E, Glader L. Cerebral palsy: Treatment of spasticity, dystonia, and associated orthopedic issues. In: UpToDate Armsby C (Ed). UpToDate, Waltham, MA. Updated July 10, 2020.
- Dali C, et al. Threshold electrical stimulation (TES) in ambulant children with CP: A randomized double-blind placebo-controlled clinical trial, Developmental Medicine and Child Neurology, June 2002; 44: 364-369.
- Durham T, et al. Surface electrical stimulation versus brace in treatment of idiopathic scoliosis, Spine, September 1990; 15(9): 888-892.
- Fehlings DL, Kirsch S, et al. Evaluation of therapeutic electrical stimulation to improve muscle strength and function in children with types II/III spinal muscular atrophy. Dev Med Child Neurol, November 2002; 44(11): 741-744.
- Kerr C, McDowell B, Cosgrove A, et al. Electrical stimulation in cerebral palsy: A randomized controlled trial. Dev Med Child Neurol, November 2006; 48(11): 868.
- Lannin N, Scheinberg A and Clark K. AACPDM systematic review of the effectiveness of therapy for children with cerebral palsy after botulinum toxin A injections. Dev Med Child Neurol 2006; 48(6): 533-539.
- Liron-Keshet S, Tirosh E, et al. The effect of therapeutic electrical stimulation in children with diplegic cerebral palsy as measured by gait analysis. Basic Appl Myol 2001; 11(3): 127-132.
- Nachemson A and Peterson L. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the brace study of the scoliosis research society, The Journal of Bone & Joint Surgery, June 1995, Vol. 77-A(6), pp. 815-822.
- The National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope through research. Last modified Nov 2018. Available online at: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope ThroughResearch/Cerebral-Palsy-Hope-Through-Research.
- O’Donnell C, et al. Electrical stimulation in the treatment of idiopathic scoliosis, Clinical Orthopedics and Related Research, April 1988, No. 229, pp. 107-113.
- Ozer K, Chesher SP and Scheker LR. Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Dev Med Child Neurol 2006; 48(7): 559-563.
- Pape K, et al. Neuromuscular approach to the motor deficits of cerebral palsy: A pilot study, Journal of Pediatric Orthopedics, September 1993; 13(5): 628-33.
- Semel-Concepcion J, et al. Neonatal brachial plexus palsies, http://www.emedicine.com/pmr/topic215.htm, Last accessed January 2014.
- Sommerfelt K, et al. Therapeutic electrical stimulation in cerebral palsy: A randomized, controlled crossover trial, Developmental Medicine and Child Neurology, September 2001; 43(9): 609-613.
- Steinbok P, et al. Therapeutic electrical stimulation following selective posterior rhizotomy in children with spastic diplegic cerebral palsy: A randomized clinical trial, Developmental Medicine and Child Neurology, 1997, Vol. 39, pp. 515-520.
- The National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope through research. Last updated June 13, 2011. Available online at: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#179393104. Last accessed January 2014.
- van der Linden ML, Hazlewood ME, et al. Electrical stimulation of gluteus maximus in children with cerebral palsy: Effects on gait characteristics and muscle strength. Dev Med Child Neurol, June 2003; 45(6): 385-390.
Medical Policy Group, May 2004 (1)
Medical Policy Administration Committee, May 2004
Available for comment May 17-June 30, 2004
Medical Policy Group, April 2006 (1)
Medical Policy Group, April 2008 (1)
Medical Policy Group, April 2010 (1): No policy changes, references added
Medical Policy Panel, February 2011
Medical Policy Group, June 2011 (2): Description updated, Policy statement changed, revision of Key Points
Medical Policy Group, November 2011 (1): Update to Key Points and References; no change to policy statement
Medical Policy Group, November 2012 (1): Update to Key Points; no change to Policy statement.
Medical Policy Panel, October 2013
Medical Policy Group, January 2014 (2): No change to policy statement. Policy no longer scheduled for regular literature reviews.
Medical Policy Group, August 2019 (3): 2019 Updates to Key Points. A peer reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.
Medical Policy Group, January 2021 (6): Updates to Description, Key Points and References.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.