CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy

This policy addresses neuromuscular electrical stimulation (NMES) devices for treating muscle atrophy. NMES is medically necessary only when muscle atrophy is present with an intact nerve supply and is used as part of post‑operative rehabilitation: either immediately post‑op as an adjunct to physical therapy when atrophy existed pre‑op, or initiated only after atrophy develops post‑op in patients whose surgical complications preclude successful PT. It is not medically necessary for prevention of atrophy, treatment of pain (e.g., patellofemoral syndrome, spinal stenosis, lumbago, strains/sprains), increasing circulation, devices with nonstandard convenience features (e.g., e‑vive), or when these criteria are not met.

"Neuromuscular stimulator devices are consideredmedically necessarywhen prescribed foranyof the following indications when muscular atrophy is present in the setting of an intact nerve supply to the..."