Neuromuscular Electrical Stimulation
Does not apply to Medicare Advantage, please refer to the Medicare policy addressing this topic.
This policy does not address functional neuromuscular electrical stimulation.
Neuromuscular electrical stimulation (NMES) involves the use of a device which transmits an electrical impulse to the skin over muscle groups by way of electrodes. This technology is proposed to stimulate the muscle while the individual is in a resting state to prevent or treat muscle atrophy, and is indicated for individuals with intact nerve supply to the muscle. This technology differs from Functional Neuromuscular Electrical Stimulation (addressed in a separate policy) which is proposed for use in individuals who are neurologically impaired (e.g., stroke, spinal cord injury).
When subjected to insufficient use, muscles atrophy, resulting in a loss of strength and mass. Muscle atrophy may occur when the limbs are immobilized after injury or surgery (e.g., casting or splinting of limb, contracture due to scarring of soft tissue as in burn lesions, hip replacement surgery). The NMES device is proposed to stimulate the motor nerves with electrical currents, generating muscle contractions to reverse muscle atrophy. The intensity and frequency of stimulation can vary based on the level of muscular function and treatment response. Examples of devices that have received 510(k) marketing clearance for the treatment of muscle atrophy include RS Medical’s RS-2m™ 2-channel and RS-4m® 4-channel muscle stimulator.
Neuromuscular electrical stimulation has also been studied in the treatment of spastic muscles related to cerebral palsy and spina bifida. For this indication, the stimulation is not intended to cause muscle contraction. Although the mechanism of action is not understood, it is thought that low-intensity stimulation (sub-threshold level) may increase muscle strength and joint mobility, leading to improved voluntary motor function. This technique is referred to threshold electrical stimulation.
H-wave stimulation is a distinct form of electrical stimulation that has been investigated primarily for treatment of pain from a variety of etiologies including diabetic neuropathy, muscle sprains, temporomandibular joint dysfunction (TMJ), and reflex sympathetic dystrophy (RSD). H-wave stimulation has also been used to accelerate wound healing such as diabetic ulcers and to improve range of motion and function to prevent muscle atrophy after orthopedic surgery. This technology produces a direct, localized effect on the conduction of underlying peripheral nerves and may be used in the home setting. It differs from transcutaneous electrical nerve stimulation (TENS) in terms of the wave form.
Neuromuscular electrical stimulation is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Neuromuscular electrical stimulation for the treatment of other conditions/diseases or using alternative methods, including, but not limited to, the following is considered investigational:
Prevention of muscle atrophy (e.g., scoliosis)
Treatment of pain
H wave stimulation
Threshold electrical stimulation
(For devices only) Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Neuromuscular electrical stimulation is considered medically appropriate if ANY ONE of the following are met:
Treatment is indicated if ALL of the following are met:
Used to treat disuse muscular atrophy (for example: casting or splinting of limb, contracture due to scarring of soft tissue as in burn lesions, hip or knee replacement surgery)
Nerve supply to muscle is intact, including brain, spinal code and peripheral nerves
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
There remains a lack of sufficient evidence to support the use of neuromuscular electrical stimulation for any condition other than disuse muscular atrophy.
American Academy of Orthopaedic Surgeons. (2013). Treatment of osteoarthritis of the knee (Evidence-based guideline, 2nd edition). Retrieved August 20, 2018 from https://www.aaos.org.
Blum, K., Chen, A., Chen, T., Prihoda, T., Schoolfield, J., DiNubile, N., et al. (2008). The H-wave device is an effective and safe analgesic for chronic pain: a meta-analysis. Advances in Therapy, 25 (7), 644-657. Abstract retrieved August 16, 2018 from PubMed.
Blum, K., Chen, A., Chen, T., Waite, R., Downs, B., Braverman, E., et al. (2009). Repetitive H-wave device stimulation and program induces significant increases in the range of motion of post-operative rotator cuff reconstruction in a double-blinded randomized placebo controlled human study. BMC Musculoskeletal Disorders, 10, 132. (Level 2 evidence)
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.
Gatewood, C.T., Tran, A.A., & Dragoo, J.L. (2017). The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review. (2017). Knee surgery, Sports Traumatology, Arthroscopy, 25 (2), 501-516. Abstract retrieved August 16, 2018 from PubMed database.
Laufer, Y., Shtraker, H., Elboim Gabyzon, M. (2014). The effects of exercise and neuromuscular electrical stimulation in subjects with knee osteoarthritis: a 3-month follow-up study. Clinical Interventions in Aging, 9, 1153-1161. Abstract retrieved August 16, 2018 from PubMed database.
Stevens-Lapsley, J., Balter, J., Wolfe, P., Eckhoff, D., & Kohrt, W. (2012). Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Physical Therapy, 92 (2), 210-226. (Level 2 evidence)
U. S. Food and Drug Administration. (2002, May). Center for Devices and Radiological Health. 510(k) Pre-market Notification Database. K021763. Retrieved August 17, 2018 from http://www.accessdata.fda.gov.
ORIGINAL EFFECTIVE DATE: 3/1980
MOST RECENT REVIEW DATE: 1/31/2019
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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