E0770 — Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
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). [...]
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals with all of the following:
- Medically refractory epileptic seizures with failure of two or more trials of single or combination antiepileptic drug therapy or intolerable side effects of antiepileptic drug therapy; and
- The individual is not a candidate for epilepsy surgery, has failed epilepsy surgery, or refuses epilepsy surgery after Shared Decision Making discussion; and
- No history of left or bilateral cervical vagotomy. The U.S. Food and Drug Administration (FDA) identifies a history of left or bilateral cervical vagotomy as a contraindication to vagus nerve stimulation.
- Functional electrical stimulation (FES) (e.g., Parastep I System) as durable medical equipment (DME) to enable members with spinal cord injury (SCI) to ambulate when ALL of the following criteria are met: Member has intact lower motor units (L1 and below) (both muscle and peripheral nerve); Member has joint stability to bear weight on upper and lower extremities, and has balance and control to maintain an upright posture independently; Member demonstrated brisk muscle contraction to neuromuscula [...]
13 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
AETNA-CPB-0191 — Vagus Nerve Stimulation
AETNA-CPB-0362
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.