E0764 — Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program
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). [...]
- 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.
8 Active Policies
AMBETTER-CP.MP.48 — Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)
CIGNA-0160-FUTURE — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
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
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