A4438 — Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews. For FES for lower limb paralysis due to SCI, documentation should demonstrate each of the listed required criteria (exact wording):
- Demonstration of intact lower motor units (L1 and below) (both muscle and peripheral nerves)
- Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently
- Demonstration of brisk muscle contraction
Key Coverage Criteria
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Transcutaneous Electrical Nerve Stimulation (TENS). [...]
- The ReActiv8 Implantable Neurostimulation System is consideredmedically necessarywhenallof the following criteria are met:
- Adult (age at least 18 years old);and
- Diagnosis of lumbar multifidus muscle dysfunction;and
- Chronic low-back pain that has lasted longer than 6 months;and
- Chronic low-back pain is non-radicular and non-neuropathic in character, with clinical records indicating that other potential sources of chronic back pain have been ruled out;and
8 Active Policies
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
ANTHEM-SURG.00158 — SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
SUREST-POL-SUREST-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Related Codes
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