OAR 410-122-0515
Neuromuscular Electrical Stimulator (NMES)


Indications and limitations of coverage and medical appropriateness:

(1)

A neuromuscular electrical stimulator (NMES) uses electrodes to transmit an electrical impulse to the skin over selected muscle groups. There are two broad categories of NMES.

(2)

NMES for treatment of muscle atrophy.

(3)

NMES devices in this category stimulate the muscle when the client is in a resting state to treat muscle atrophy.

(4)

The Division of Medical Assistance Programs (Division) will cover NMES to treat muscle atrophy specific to disuse atrophy where nerve supply to the muscle is intact (including brain, spinal cord and peripheral nerves) and to treat other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).

(5)

NMES to enhance functional activity of neurologically impaired clients: Specifically, the Division will cover NMES used to improve the ability to walk in clients with Spinal Cord Injury (SCI).

(6)

This type of NMES is commonly referred to as functional electrical stimulation (FES). FES devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence.

(7)

The Division will only cover NMES/FES for SCI clients for walking, who meet the following criteria:

(a)

Client has completed at least 32 physical therapy sessions, directly performed one-on-one with the physical therapist with the NMES/FES device over a trial period of three months, with the specific goal of using the NMES/FES device to achieve walking, not to reverse or retard muscle atrophy;

(b)

Therapists with the sufficient skills to provide these services are only employed at inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities;

(c)

The physician treating the client for SCI will use this trial period to properly evaluate the person’s ability to use the NMES/FES frequently and for the long term; and

(d)

The client meets all of the following characteristics:

(e)

Intact lower motor units (L1 and below) (both muscle and peripheral nerve);

(f)

Muscle and joint stability for weight bearing at upper and lower extremities that demonstrates balance and control to maintain an upright support posture independently;

(g)

Demonstrated brisk muscle contraction to NMES and sensory perception of electrical stimulation sufficient for muscle contraction;

(h)

High motivation, commitment and cognitive ability to use NMES/FES devices for walking;

(i)

Can transfer independently and demonstrates independent standing tolerance for at least three minutes;

(j)

Demonstrated hand and finger function to manipulate controls;

(k)

At least six-month post recovery spinal cord injury and restorative surgery;

(l)

Hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and

(m)

Demonstrated willingness to use the device long-term;

(n)

NMES/FES for walking is not covered in an SCI client with any of the following:

(A)

Cardiac pacemaker;

(B)

Severe scoliosis or severe osteoporosis;

(C)

Skin disease or cancer at area of stimulation;

(D)

Irreversible contracture;

(E)

Autonomic dysflexia; or

(F)

Treatment of muscle weakness due to the following conditions (not all-inclusive):
(i)
Stroke; spinal cord injury; peripheral nerve injury; other central nervous system, spinal or peripheral nerve disease/condition affecting motor and/or sensory pathways to/from the muscles being stimulated;
(ii)
Documentation requirements: Submit documentation that supports coverage criteria as specified in this rule are met.

(8)

Procedure codes:

(a)

A4595, Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES) — Includes all supplies necessary for the effective use of the device — Division will purchase — Prior authorization (PA) required;

(b)

E0745, Neuromuscular stimulator, electronic shock unit — Division will rent — Purchased after no more than 13 months of rental — PA required.

Source: Rule 410-122-0515 — Neuromuscular Electrical Stimulator (NMES), https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0515.

410‑122‑0010
Definitions
410‑122‑0020
Orders
410‑122‑0040
Prior Authorization
410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions
410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients)
410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding
410‑122‑0182
Legend
410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing
410‑122‑0186
Payment Methodology
410‑122‑0188
DMEPOS Rebate Agreements
410‑122‑0200
Pulse Oximeter for Home Use
410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea
410‑122‑0203
Oxygen and Oxygen Equipment
410‑122‑0204
Nebulizer
410‑122‑0205
Respiratory Assist Devices
410‑122‑0206
Intermittent Positive Pressure Breathing
410‑122‑0207
Respiratory Supplies
410‑122‑0208
Suction Pumps
410‑122‑0209
Tracheostomy Care Supplies
410‑122‑0210
Ventilators
410‑122‑0211
Cough Stimulating Device
410‑122‑0220
Pacemaker Monitor
410‑122‑0240
Apnea Monitors for Infants
410‑122‑0250
Breast Pumps
410‑122‑0260
Home Uterine Monitoring
410‑122‑0280
Heating/Cooling Accessories
410‑122‑0300
Light Therapy
410‑122‑0320
Manual Wheelchair Base
410‑122‑0325
Power Wheelchair Base
410‑122‑0330
Power-Operated Vehicle
410‑122‑0340
Wheelchair Options/Accessories
410‑122‑0360
Canes and Crutches
410‑122‑0365
Standing and Positioning Aids
410‑122‑0375
Walkers
410‑122‑0380
Hospital Beds
410‑122‑0400
Pressure Reducing Support Surfaces
410‑122‑0420
Hospital Bed Accessories
410‑122‑0475
Therapeutic Shoes for Diabetics
410‑122‑0510
Osteogenesis Stimulator
410‑122‑0515
Neuromuscular Electrical Stimulator (NMES)
410‑122‑0520
Glucose Monitors and Diabetic Supplies
410‑122‑0525
External Insulin Infusion Pump
410‑122‑0540
Ostomy Supplies
410‑122‑0560
Urological Supplies
410‑122‑0580
Bath Supplies
410‑122‑0590
Patient Lifts
410‑122‑0600
Toilet Supplies
410‑122‑0620
Miscellaneous Supplies
410‑122‑0625
Surgical Dressing
410‑122‑0630
Incontinent Supplies
410‑122‑0640
Eye Prostheses
410‑122‑0655
External Breast Prostheses
410‑122‑0658
Gradient Compression Stockings/Sleeves
410‑122‑0660
Orthotics and Prosthetics
410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses
410‑122‑0678
Dynamic Adjustable Extension/Flexion Device
410‑122‑0680
Facial Prostheses
410‑122‑0700
Negative Pressure Wound Therapy Pumps
410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0515’s source at or​.us