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
- Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
- Documentation of prior treatments and treatment failures where applicable (e.g., prior pneumatic dilation, prior Heller myotomy, prior botulinum toxin injection) — several POEM reports specify use as 'rescue' after failed prior interventions.
- For stent placement or palliative radiotherapy: documentation of inoperable/unresectable primary esophageal cancer and symptom burden (dysphagia score), and life expectancy considerations (to guide stent vs brachytherapy selection).
- No explicit documentation requirements, test-result requirements, or medical-record documentation instructions are specified in this document excerpt.
- Objective pre- and post-treatment measures used in trials and expected in documentation: Eckardt score, LES resting pressure (manometry), timed barium esophagogram results (esophageal emptying), EndoFLIP/EGJ distensibility where used, and follow-up endoscopy/pH monitoring for reflux after POEM.
- For dysphagia therapies generally: baseline and follow-up instrumental swallowing assessment such as video-fluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) are commonly used and reported.
Key Coverage Criteria
- 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;
- Esophageal dilation for the treatment of symptomatic obstruction of the esophagus;
20 Active Policies
ANTHEM-DME.00022, DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
ANTHEM-CG-DME-03, CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CIGNA-0160, Electrical Stimulation Therapy and Devices in a Home Setting
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
AETNA-CPB-0625, Dysphagia Therapy
AETNA-CPB-0680, Electrical Stimulation for Chronic Ulcers
AETNA-CPB-0679, Levator Syndrome Treatments
AETNA-CPB-0011, Peripheral Electrical Nerve Stimulation for Pain
AETNA-CPB-0614, Huntington's Disease
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0755, Motor Cortex Stimulation
AETNA-CPB-0362, Spasticity Management
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
AMBETTER-CP.MP.137, Fecal Incontinence Treatments
AMBETTER-CP.MP.48, Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)
MED201.026, Surface Electrical Stimulation
BCBSIL-SUR710.018, Sacral Nerve Neuromodulation/Stimulation
BCBSIL-MED201.026, Surface Electrical Stimulation
BCBSMT-SUR710.018, Sacral Nerve Neuromodulation/Stimulation
BCBSMT-MED201.026, Surface Electrical Stimulation
Related Codes
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