E0770, Functional electrical stimulator, transcutaneous stimulation of nerve and/or
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.
- For FES (Parastep) ambulatory coverage: documentation that ALL selection criteria are met, including intact lower motor units (L1 and below), joint stability and balance to bear weight, brisk muscle contraction to NMES and sensory perception sufficient for contraction, cognitive ability and motivation, independent transfers and ability to stand at least 3 minutes, adequate hand/finger function to manipulate controls, at least 6 months post recovery of SCI and restorative surgery, absence of hip/knee degenerative disease and no history of long bone fracture secondary to osteoporosis, and completion of at least 32 physical therapy training sessions with the device over a 3-month period.
- For replacement of FES/NMES/phrenic/diaphragmatic/sacral anterior roots systems: documentation that original device met medical necessity criteria, device is no longer under warranty, and device cannot be repaired.
Key Coverage Criteria
- Implantable vagus nerve stimulators are proven and medically necessary for treating epilepsy in individuals who have medically refractory seizures with failure of two or more trials of antiseizure drugs (or intolerable AED effects), are not candidates for epilepsy surgery (or have failed/refuse after shared decision making), and have no history of left or bilateral cervical vagotomy.
- 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 [...]
- Replacement of a FES for walking when the original FES met medical necessity criteria and is no longer under warranty and cannot be repaired.
- FES / NMES to assist gait in patients with incomplete spinal cord injury.
- Functional Electrical Stimulation / Neuromuscular Electrical Stimulation for Chronic Obstructive Pulmonary Disease (NMES to improve exercise capacity/rehabilitation in moderate-to-severe COPD)
- Sacral Nerve Stimulation for the Treatment of Chronic Constipation and Fecal Incontinence (sacral neuromodulation for refractory constipation and fecal incontinence)
13 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
UHC-POL-vagus-nerve-stimulation, Vagus and External Trigeminal Nerve Stimulation
Related Codes
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