Or. Admin. Code § 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 shall 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 shall 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 shall 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 (3) 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 practitioner 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 shall purchase - Prior authorization (PA) required;

(b) E0745, Neuromuscular stimulator, electronic shock unit - Division shall rent - Purchased after no more than 10 months of rental - PA required.

Notes

Or. Admin. Code § 410-122-0515

OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 70-2023, minor correction filed 08/19/2023, effective 8/19/2023; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065