Neuromuscular Electrical Stimulation
Does not apply to Medicare Advantage, please refer to the Medicare policy addressing this topic.
Neuromuscular electrical stimulation (NMES) involves using a device that transmits an electrical impulse to activate muscle groups through electrodes. There are two broad categories of NMES. One type stimulates the muscle when the individual is at rest. The nerve supply to the muscle is intact and may include brain, spinal cord and/or peripheral nerve injury, as well as other non-neurological reasons for disuse atrophy. The second type is used to enhance the functional activity of individual; and is an orthotic device proposed for motor restoration in hemiplegia and secondary dysfunction (e.g., muscle atrophy and alterations in cardiovascular function and bone density) associated with damage to motor nerve pathways.
Functional Neuromuscular Electrical Stimulation
Functional neuromuscular electrical stimulation (NMES) involves the use of an orthotic device with microprocessor-controlled electrical muscular stimulation. These devices are being developed with the intent to restore function to individuals with damaged or destroyed nerve pathways (e.g., spinal cord injury, stroke, multiple sclerosis, cerebral palsy).
One application of functional NMES is to restore upper extremity functions such as grasp-release, forearm pronation, and elbow extension in individuals with stroke, or C5 and C6 quadriplegia (e.g., FreeHand® System, HandMaster™) through an implantable upper extremity neuroprosthesis.
Other neural prosthetic devices have been developed for functional NMES in individuals with footdrop (e.g., WalkAide® System, NESS L300®, Odstock® Dropped Foot Stimulator Pace). Functional electrical stimulation of the peroneal nerve has been suggested for these individuals as an aid in raising the toes during the swing phase of ambulation. Footdrop can have various causes such as cerebral palsy, stroke or multiple sclerosis (MS).
Functional electrical stimulation has also been proposed for spinal cord-injured (T4-T12) individual’s assistance with standing and walking (e.g., Parastep®). Using percutaneous stimulation, the device delivers electrical pulses to selected nerves at the quadriceps (for knee extension), the common peroneal nerve (for hip flexion), and the paraspinals and gluteals (for trunk stability). Individuals use a walker or elbow-support crutches for further support. The electrical impulses are controlled by a microchip attached to the individual’s belt that synchronizes and distributes the signals. In addition, there is a finger-controlled switch that permits individual activation of the stepping.
Other devices include a reciprocating gait orthosis with electrical stimulation. This orthosis is a cumbersome hip-knee-ankle-foot device linked together with a cable at the hip joint. The use of this device may be limited by the difficulties in putting the device on and taking it off.
H-Wave Electrical Stimulation
H-wave stimulation is a distinct form of electrical stimulation that produces a direct, localized effect on the conduction of underlying peripheral nerves. It differs from transcutaneous electrical nerve stimulation (TENS) in terms of the wave form. It has been evaluated primarily as a pain treatment from a variety of etiologies including diabetic neuropathy, muscle sprains, temporomandibular joint dysfunction (TMJ), and reflex sympathetic dystrophy (RSD). It has also has been studied for wound healing and improving post-surgical range of motion.
Threshold Electrical Stimulation
Threshold electrical stimulation is described as the delivery of low-intensity electrical stimulation to target spastic muscles during sleep at home. Stimulation is provided by a small electrical generator, lead wires, and surface electrodes that are placed over the targeted muscles. The stimulation is not intended to cause muscle contraction. Although the mechanism of action is not understood, it is thought that low-intensity stimulation may increase muscle strength and joint mobility, leading to improved voluntary motor function. The technique has been used most extensively in children with spastic diplegia related to cerebral palsy, but also in those with other motor disorders, such as spina bifida. However, the studies published to date do not demonstrate threshold electrical stimulation is effective.
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.
Neuromuscular electrical stimulation or functional neuromuscular electrical stimulation as a technique to restore function following nerve damage or nerve injury or for the treatment of all conditions/diseases, including, but not limited to, the following is considered investigational:
As a technique to provide ambulation in individuals with spinal cord injuries
To provide upper extremity function in individuals with nerve damage (e.g. spinal cord injury or stroke)
To improve ambulation in individuals with foot drop caused by nerve damage (e.g. post stroke, multiple sclerosis)
In the treatment of scoliosis
To reduce spasticity or facilitate voluntary motor control in individuals with spinal cord injury, cerebral palsy, or other upper motor neuron disorders
In the treatment of denervated muscles
In the treatment of pain
In the treatment of dysphagia
As a muscle-strengthening regimen in healthy individuals
H wave stimulation for all indications is considered investigational.
Threshold electrical stimulation as a treatment of motor disorders, including but not limited to cerebral palsy, is considered not medically necessary.
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A compliance monitor device is not considered a necessary component of a therapeutic electrical stimulator.
There is a lack of randomized controlled trials providing evidence of the efficacy of neuromuscular electrical stimulation (NMES) for the indications listed as investigational. Health outcomes, such as the ability to perform activities of daily living or quality of life, have also not been reported.
BlueCross BlueShield Association. Medical Policy Reference manual. (8:2017). Functional neuromuscular electrical stimulation (8.03.01). Retrieved September 15, 2017 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) (160.13). Retrieved September 15, 2017 from http://www.cms.gov.
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.
Kwon, D., Kim, J., Kim, Y., An, S., Kwak, J., Lee, S., et al. (2017, June) Short-term microcurrent electrical neuromuscular stimulation to improve muscle function in the elderly. Medicine, 96 (26), e7407. (Level 2 evidence)
Lee, Y., Lin, K., Cheng, H., Wu, C., Hsieh, Y., and Chen, C. (2015) Effects of combining robot-assisted therapy with neuromuscular electrical stimulation on motor impairment, motor and daily function, and quality of life in patients with chronic stroke: a double-blinded randomized controlled trial. Journal of NeuroEngineering and Rehabilitation (2015) 12:96. (Level 2 evidence)
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.
Quandt, F. and Hummel, F. (2014) The influence of functional electrical stimulation on hand motor recovery in stroke patients: a review. Experimental & Translational Stroke Medicine. 2014, 6:9 (Level 4 evidence)
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.
Walker, J., Ryan, S., & Coburn, T. (2011) Does threshold electrical stimulation benefit children with spina bifida? Clinical Orthopedics and Related Research. 469 (5), 1297-301. (Level 4 evidence)
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)
ORIGINAL EFFECTIVE DATE: 3/1980
MOST RECENT REVIEW DATE: 10/26/2017
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