E0745 — Neuromuscular stimulator, electronic shock unit
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium 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). [...]
- Telerehabilitation delivery of swallowing therapy (as an alternative delivery model; limited evidence)
- Speech therapy for treatment of dysphagia, regardless of the presence of a communication disability, for members who meet the criteria set forth below:
- Member exhibits weight loss or malnutrition because he/she has dysphagia and is unable to obtain adequate nutrition orally;
- Member has a history of, or is at high-risk for, recurrent aspirations or choking;
- Member is unable to swallow and has a nasogastric or gastrotomy tube for nutrition;
20 Active Policies
AMBETTER-CP.MP.137 — Fecal Incontinence Treatments
AMBETTER-CP.MP.48 — Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)
CIGNA-0160-FUTURE — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
CIGNA-0160 — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
Related Codes
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