A4560, Neuromuscular electrical stimulator (nmes), disposable, replacement only
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
- For FES (Parastep) ambulatory coverage: documentation that ALL selection criteria are met, including intact lower motor units (L1 and below), joint stability and balance to bear weight, brisk muscle contraction to NMES and sensory perception sufficient for contraction, cognitive ability and motivation, independent transfers and ability to stand at least 3 minutes, adequate hand/finger function to manipulate controls, at least 6 months post recovery of SCI and restorative surgery, absence of hip/knee degenerative disease and no history of long bone fracture secondary to osteoporosis, and completion of at least 32 physical therapy training sessions with the device over a 3-month period.
- For replacement of FES/NMES/phrenic/diaphragmatic/sacral anterior roots systems: documentation that original device met medical necessity criteria, device is no longer under warranty, and device cannot be repaired.
- For NMES for disuse atrophy: documentation that nerve supply to the muscle is intact and the disuse atrophy is due to listed non-neurological causes (contractures due to burn scarring; failure to respond to physical therapy after major knee surgery; failure to respond to physical therapy after casting/splinting; or recent hip replacement prior to initiation of physical therapy), and documentation of failure to respond to appropriate physical therapy when required.
Key Coverage Criteria
- Functional electrical stimulation (FES) (e.g., Parastep I System) as durable medical equipment (DME) to enable members with spinal cord injury (SCI) to ambulate when ALL of the following criteria are met: Member has intact lower motor units (L1 and below) (both muscle and peripheral nerve); Member has joint stability to bear weight on upper and lower extremities, and has balance and control to maintain an upright posture independently; Member demonstrated brisk muscle contraction to neuromuscula [...]
- Replacement of a FES for walking when the original FES met medical necessity criteria and is no longer under warranty and cannot be repaired.
- FES / NMES to assist gait in patients with incomplete spinal cord injury.
- Functional Electrical Stimulation / Neuromuscular Electrical Stimulation for Chronic Obstructive Pulmonary Disease (NMES to improve exercise capacity/rehabilitation in moderate-to-severe COPD)
- Sacral Nerve Stimulation for the Treatment of Chronic Constipation and Fecal Incontinence (sacral neuromodulation for refractory constipation and fecal incontinence)
- Wearable low-frequency NMES devices (e.g., geko T-3 and geko W-3 stimulating the common peroneal nerve) to increase local blood circulation, reduce edema, prevent venous thrombosis, and increase microcirculatory blood flow in lower limb with venous insufficiency and/or ischemia to support wound or tissue healing (device indications described; clinical value noted as lacking robust evidence).
7 Active Policies
ANTHEM-CG-DME-03, CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
AETNA-CPB-0677, Functional Electrical Stimulation and Neuromuscular Electrical Stimulation
MED201.026, Surface Electrical Stimulation
BCBSIL-MED201.026, Surface Electrical Stimulation
BCBSMT-MED201.026, Surface Electrical Stimulation
Related Codes
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