A4594 — Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece 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). [...]
- Partial or complete paralysis may occur when the brain and spinal cord are damaged by injury, stroke or acute disease.
- Neuromuscular electrical stimulation (NMES) used as part of physical therapy to retrain voluntary muscle control and preserve range of motion.
- NMES used in rehabilitation to accelerate and improve functional recovery after brain or spinal cord damage.
- Neuromuscular electrical stimulation (NMES) as a complementary approach to rehabilitation to elicit muscle contraction.
- To control edema in an immobilized extremity following a documented injury or surgical intervention.
4 Active Policies
HUMANA-FUNCTIONAL-ELECTRICAL-STIMULATORS-NON-PAIN-MA — Functional Electrical Stimulators (Non-Pain) - Medicare Advantage
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
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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