E0764, Functional neuromuscular stimulation, transcutaneous stimulation of sequential
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Record of prior conservative treatments tried and failed (e.g., trials of oral antispasmodics such as baclofen, phenol injections, botulinum toxin injections, physical therapy, bracing) including dates and responses.
- Assessment documenting ambulatory potential and intrinsic lower extremity motor power (for SPR/SDR: documentation that impairment is due to spasticity rather than profound weakness), and patient/caregiver capacity and motivation to participate in post-operative rehabilitation.
- Age documentation when relevant (e.g., children aged 2–6 years are described as optimal candidates for SPR/SDR).
Key Coverage Criteria
- SPR/SDR in children with CP when there is demonstrated limitation in ambulation primarily due to spasticity and not due to intrinsic muscle weakness.
- SPR/SDR for children who have tried and failed conservative medical management for spasticity (including oral baclofen or other muscle relaxants, phenol injections, physical therapy, bracing, orthopedic surgery) and who have capacity and motivation to participate in post-operative rehabilitation.
- SPR/SDR considered optimal for children aged approximately 2 to 6 years (children in this age range are described as optimal candidates).
- Selective tibial nerve neurotomy (selective neurotomy) as a surgical option to treat focal spastic equinovarus foot in adults (post-stroke / hemiplegic patients) — shown to reduce ankle stiffness and impairments associated with spastic equinovarus foot.
- Selective peripheral neurotomy / microsurgical selective peripheral neurotomy for treatment of focal spasticity (upper or lower limb) where focal surgical denervation is appropriate.
- Selective percutaneous myofascial lengthening (SPML) for release of tight myofascial/tendon bands (e.g., hip adductors, hamstrings, gastrocnemius/Achilles) in children with spastic CP when primary contracture interferes with walking, sitting, or causes joint subluxation.
8 Active Policies
HUMANA-FUNCTIONAL-ELECTRICAL-STIMULATORS-NON-PAIN-MA, Functional Electrical Stimulators (Non-Pain)
ANTHEM-DME.00022, DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
AETNA-CPB-0362, Spasticity Management
Related Codes
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