E0743 — External lower extremity nerve stimulator for restless legs syndrome, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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). [...]
5 Active Policies
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
ANTHEM-DME.00011 — DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
CARELON-sleep-disorder-management-2025-11-15 — Sleep Disorder Management
UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Related Codes
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