mp-718 - Medical Policies - Alabama
Neuromuscular Electrical Stimulation (NMES)
Policy Number: MP-718
Latest Review Date: August 2021
Policy Grade: A
Neuromuscular Electrical Stimulation (NMES) may be considered medically necessary for disuse atrophy where the nerve supply to the muscle is intact and the member has any of the following non-neurological reasons for disuse atrophy:
- Previous casting or splinting of a limb when unable to participate in physical therapy
- Major knee surgery (e.g., total knee replacement) when there is failure to respond to physical therapy
- Sprain of cruciate ligament of knee
- Contractures due to scarring of soft tissue (e.g. burn scarring)
- Hip replacement prior to initiation of physical therapy
Neuromuscular Electrical Stimulation (NMES) for all other indications, including use where the nerve supply to the muscle is not intact, and injuries not meeting the above criteria are considered investigational.
A form-fitting conductive garment (E0731) may be considered medically necessary when:
1. It has received permission or approval for marketing by the Food and Drug Administration;
2. It has been prescribed by a physician for use in delivering covered NMES treatment; and
3. One of the medical indications outlined below is met:
- The member cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires; or
- The member has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires; or
- The member requires electrical stimulation beneath a cast to treat disuse atrophy, where the nerve supply to the muscle is intact; or
- The member has a medical need for rehabilitation strengthening following an injury where the nerve supply to the muscle is intact.
DESCRIPTION OF PROCEDURE OR SERVICE:
Neuromuscular electrical stimulation (NMES) is a two-channel device that transmits an electrical impulse through the skin (transcutaneous) to selected muscle groups by way of electrodes. These devices are designed for use in the home for treating muscle atrophy and stimulates the muscle when the individual is in a resting state.
NMES is used as a treatment modality for disuse atrophy due to a condition such as limb casting or hip replacement surgery, where the nerve supply to the muscle is intact. The NMES device encompasses a portable stimulator with electrodes that are placed on the skin over targeted muscle or muscle group. The current passes through the electrodes into the body, and the motor nerves are stimulated, causing a muscle contraction. The intensity and frequency of stimulation can vary based on the level of muscular function and response to treatment.
Literature reviewed performed through August 2021.
SUMMARY OF EVIDENCE:
Although the evidence is limited, NMES for the treatment of disuse atrophy in individuals where the nerve supply to the muscle is intact appears to be considered standard of care. There is some evidence that the use of NMES may be an effective rehabilitative regimen to prevent muscle atrophy associated with prolonged knee immobilization following ligament reconstruction surgery or injury; however, controlled clinical trials are necessary to determine if the addition of NMES to the rehabilitation program will improve health outcomes.
PRACTICE GUIDELINES AND POSITION STATEMENTS:
American Heart Association/American Stroke Association (AHA/ASA)
In its Guidelines for Adult Stroke Rehabilitation and Recovery, the AHA/ASA state that NMES combined with therapy may improve spasticity, but there is insufficient evidence that the addition of NMES improves functional gait or hand use. The AHA/ASA guidelines are endorsed by the American Academy of Physical Medicine and Rehabilitation and the American Society of Neurorehabilitation.
American Physical Therapy Association, Orthopaedic Section
Neuromuscular electrical stimulation should be used for 6 to 8 weeks to augment muscle strengthening exercises in patients after ACL reconstruction to increase quadriceps muscle strength and enhance short-term functional outcomes.
U.S. Preventive Services Task Force Recommendations
Neuromuscular electrical stimulation, Empi 300 PV, NexWave, NMES, ARPNeuro RX100, Muscle atrophy, kneehab®
APPROVED BY GOVERNING BODIES:
A variety of NMES devices have been cleared by the U.S. Food and Drug Administration (FDA) and are available for home use.
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 and will be reviewed for medical necessity. Special benefit consideration may apply. Refer to member’s benefit plan.
|A4595||Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)|
|E0731||Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)|
|E0744||Neuromuscular stimulator for scoliosis|
Neuromuscular stimulator, electronic shock unit
- American Academy of Orthopaedic Surgeons Second Look, Exercise Benefits Total Knee Arthroplasty and NMES. J Orthop Sports Phys Ther. 2004 Jan;34(1):21-9. Neuromuscular Electrical Stimulation for Quadriceps Muscle Strengthening after Bilateral Total Knee Arthroplasty: A Case Series. Department of Physical Therapy, University of Florida.
- Bistolfi A, et al. Evaluation of the effectiveness of neuromuscular electrical stimulation after total knee arthroplasty: a meta-analysis. Am J Phys Med Rehabil 2018 Feb;97(2):123-130.
- de Oliveira Melo M, Aragão FA, Vaz MA. Neuromuscular electrical stimulation for muscle strengthening in elderly with knee osteoarthritis - a systematic review. Complement Ther Clin Pract. 2013 Feb;19(1):27-31.
- IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
- Kneehab XP® Conductive Garment, 510(k) Summary; accessed at accessdata.fda.gov. Maffiuletti NA, Gondin J, et al. Clinical Use of Neuromuscular Electrical Stimulation for Neuromuscular Rehabilitation: What Are We Overlooking? Arch Phys Med Rehabil, 99 (4), 806-812. Apr 2018.
- Logerstedt, D. et al. Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain Revision. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association2017.https://www.orthopt.org/uploads/content_files/files/Knee%20Ligament%20Sprain%20CPG%20-%202017.pdf
- Monaghan B, Caulfield B,O’MathúnaDP. Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD007177. DOI:10.1002/14651858.CD007177.
- Nussbaum, E. et al. Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice. Physiotherapy Canada. Volume 69 Issue 5, Special Issue 2017, pp. 1-76.
- 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 Feb;92(2):210-26.
- Talbot LA, Brede E, Metter EJ. Effects of Adding Neuromuscular Electrical Stimulation to Traditional Military Amputee Rehabilitation. Mil Med. 2017 Jan;182(1):e1528-e1535.
- Walls RJ, McHugh G, O'Gorman DJ, et al. Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study. BMC Musculoskelet Disord. 2010 Jun 14;11:119.
- Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-e169.
Medical Policy Group, July 2020 (6): New policy, DRAFT dates extended through August 31, 2020.
Medical Policy Group, August 2021 (6): Updates to Description, Key Points, Coding and References. Policy statement updated to remove “not medically necessary,” no change to policy intent.
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.