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