BlueCross BlueShield of Tennessee Medical Policy Manual

Functional Neuromuscular Electrical Stimulation

Does not apply to Medicare Advantage, please refer to the Medicare policy addressing this topic.

DESCRIPTION

Functional neuromuscular electrical stimulation (NMES) involves the use of an orthotic device with microprocessor-controlled electrical muscular stimulation. These devices are proposed to restore function to individuals with damaged or destroyed nerve pathways (e.g., spinal cord injury, stroke, multiple sclerosis, cerebral palsy). This approach to rehabilitation focuses on the restoration of useful movements such as standing, stepping, pedaling for exercise, reaching or grasping.  Proposed applications of functional neuromuscular electrical stimulation include the following: to restore upper-extremity functions such as grasp-release, forearm pronation, and elbow extension in individuals with stroke, or C5 and C6 tetraplegia; treatment of foot drop (weakness of foot and ankle that causes reduced dorsiflexion and difficulty with ambulation); provide individuals with spinal cord injury the ability to stand and walk.

Functional neuromuscular stimulators are closed–loop systems that provide feedback information on muscle force and joint position, thus allowing constant modification of stimulation parameters, which are required for complex activities (e.g., walking). Examples of FDA-cleared devices include the HandMaster™ (now named NESS H200®) cleared for maintaining or improving range of motion, reducing muscle spasm, preventing or retarding muscle atrophy, providing muscle re-education, improving circulation, and provision of hand active range of motion and function for individuals with C5 tetraplegia. Systems intended for individuals with footdrop to assist with ankle dorsiflexion during the swing phase of gait include the WalkAide® System, the ODFS® (Odstock® Dropped Foot Stimulator), NESS L300®, and MyGait® Stimulation System. The Parastep® Ambulation System is FDA approved to enable appropriately selected skeletally mature spinal cord injured individuals (level C6-T12) to stand and attain limited ambulation and/or take steps, with assistance if required, following a prescribed period of physical therapy training in conjunction with rehabilitation management of spinal cord injury.

Note: This policy does not refer to commercially available exercycles that use electrical muscle stimulation technology as a means of physical therapy and exercise for individuals with a spinal-cord-injury. When using the exercycle the individual's legs are wrapped in fabric strips that contain electrodes to stimulate the muscles, thus permitting the individual to pedal. While these exercycles are sometimes called functional neuromuscular exercisers; they are not functional neuromuscular electrical stimulation devices. The exercycles are considered a physical therapy modality.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

There remains a lack of randomized controlled trials providing evidence of the efficacy of functional neuromuscular electrical stimulation (NMES).

SOURCES 

Bethoux, F., Rogers, H.L., Nolan, K.J., Abrams, G.M., Annaswamy, T.M., Brandstater, M., et al. (2014). The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair, 28 (7), 688-697. Abstract retrieved August 15, 2018 from PubMed database.

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2018). Functional neuromuscular electrical stimulation (8.03.01). Retrieved August 13, 2018 from Blue Web. (31 articles and/or guidelines reviewed)

Centers for Medicare & Medicaid Services. CMS.gov. National Coverage Determination (NCD) for neuromuscular electrical stimulation (NMES) (160.12). Retrieved October 19, 2015 from http://www.cms.gov.   

Kluding, P.M., Dunning, K., O’Dell, M.W., Wu, S.S., Ginosian, J., Feld, J., & McBride, K. (2013). Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke, 44 (6), 1660-1669. Abstract retrieved August 15, 2018 from PubMed database.

National Institute for Health and Care Excellence (2009, January). Interventional procedure guidance 278: Functional electrical stimulation for drop foot of central neurological origin. Retrieved September 20, 2016 from www.nice.org.uk.

National Institute of Neurological Disorders and Stroke. (2018). Cerebral palsy: hope through research. Retrieved August 16, 2018 from www.ninds.nih.gov.

O’Dell, M.W., Dunning, K., Kluding, P., Wu, S.S., Feld, J., Ginosian, J., & McBride, K. (2014). Response and prediction of improvement in gait speed from functional electrical stimulation in persons with poststroke drop foot. PM & R, 6 (7), 587-601. Abstract retrieved August 15, 2018 from PubMed database.

U. S. Food and Drug Administration. (1993, October). Center for Devices and Radiological Health. 510(k) Pre-market Notification Database. K933176. Retrieved February 7, 2011 from http://www.accessdata.fda.gov. 

U. S. Food and Drug Administration. (2008, January). Center for Devices and Radiological Health. 510(k) Pre-market Notification Database. K080219. Retrieved February 7, 2011 from http://www.accessdata.fda.gov. 

Winifred S. Hayes Inc. Hayes Brief. (2015, July; last update search June 2017). Functional electrical stimulation (FES) for treatment of foot drop in multiple sclerosis patients. Retrieved September 15, 2017 from www.Hayesinc.com/subscribers (36 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2017, November). Functional electrical stimulation for rehabilitation following spinal cord injury. Retrieved August 13, 2018 from www.Hayesinc.com/subscribers (56 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  3/1980

MOST RECENT REVIEW DATE:  1/31/2019

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment. 

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