Neuromuscular Electrical Stimulation (NMES) Information posted May 9, NMES for Muscle Atrophy

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1 Neuromuscular Electrical Stimulation (NMES) Information posted May 9, 2008 NMES is a benefit of the CSHCN Services Program for the treatment of muscle atrophy or to enhance the functional activity of neurologically impaired clients. NMES may be reimbursed with prior authorization. Prior authorization requests for NMES must include documentation of a spinal cord injury or disuse atrophy that is refractory to conventional therapy. NMES may be reimbursed using the following procedure codes: 2/F /8/F J/L-E0720 J/L-E0730 J/L-E0731 J/L-E0745 J/L-E0762 J/L-E0764 The purchase of a NMES device is limited to once per five years. For information about seeking reimbursement for NMES supplies, see the section below entitled NMES/TENS Supplies. For information about NMES conductive garments, see the section below entitled NMES/TENS Garments. See the following two sections for information related to NMES for specific diagnoses. NMES for Muscle Atrophy NMES may be reimbursed if it is used to treat muscle disuse atrophy when brain, spinal cord, and peripheral nerve supply to the muscle is intact, as well as other nonneurological reasons. Examples of NMES treatment for non-neurological reasons include, but are not limited to, 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. NMES for Walking in Clients with Spinal Cord Injury (SCI) The type of NMES that is used to enhance the ability of SCI clients to walk is commonly referred to as functional electrical stimulation (FES). Reimbursement for NMES/FES for walking is limited to SCI clients who have completed a training program that consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period of physical therapy will enable the physician treating the client for SCI to properly evaluate the client's ability to use NMES/FES devices frequently and for the long term. Physical therapy that is necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. Note: The goal of physical therapy must be to train SCI clients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy. NMES/FES that is used for walking is a benefit for clients with SCI who meet all of the following characteristics: Clients with intact lower motor unit (L1 and below) (both muscle and peripheral nerve)

2 Clients with muscle and joint stability for weight bearing at upper and lower extremities who can demonstrate the balance and control necessary to maintain an upright support posture independently Clients that demonstrate brisk muscle contraction with NMES and have sensory perception electrical stimulation sufficient for muscle contraction Clients that possess the motivation, commitment, and cognitive ability that is necessary to use such devices for walking Clients that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes Clients that can demonstrate hand and finger function necessary to manipulate controls. Clients with at least 6-month post recovery spinal cord injury and restorative surgery Clients with hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis Clients who have demonstrated a willingness to use the device in the long term NMES/FES that is used for walking is not a benefit for clients who have any of the following conditions: Clients with cardiac pacemakers Severe scoliosis or severe osteoporosis Skin disease or cancer at area of stimulation Irreversible contracture Autonomic dysflexia Transcutaneous Electrical Nerve Stimulation (TENS) The rental of a TENS device, accessories, and supplies is a benefit of the CSHCN Services Program for the treatment of a condition that indicates acute postoperative pain or to determine if TENS will benefit a client who has chronic pain. TENS may be reimbursed using the following procedure codes: 2/F /8/F J/L-E0720 J/L-E0730 J/L-E0731 J/L-E0745 J/L-E0762 J/L-E0764 Once it has been determined that TENS should be continued for chronic pain and the client has been trained to use the stimulator, the CSHCN Services Program will no longer reimburse TENS therapy as an outpatient or office service. For information about seeking reimbursement for TENS supplies, see the section below entitled NMES/TENS Supplies. For information about TENS conductive garments, see the section below entitled NMES/TENS Garments. See the following two sections for specific information about TENS rental and purchase.

3 TENS Rental The rental of a TENS device may be considered for prior authorization with documentation of a condition that indicates acute postoperative pain or chronic pain that is refractory to conventional therapy. The rental of a TENS may be considered before purchase and is limited to a trial period of one month. One additional month s rental of the TENS device may be considered with documentation of medical necessity. Supplies, such as lead wires and electrodes, are considered to be part of the rental and will not be reimbursed separately. Garments may be considered for reimbursement during the rental period when medically necessary. TENS Purchase The purchase of a TENS device, accessories, and supplies may be considered only after a one month trial period. In addition, the purchase of a TENS device will be considered for prior authorization with documentation of the following: Acute postoperative pain or chronic pain that is refractory to conventional therapy. Successful test stimulation (during rental or other therapeutic period) that showed improvement as measured by demonstrated increase in range of motion. Improved ability to complete activities of daily living or perform activities outside the home. Successful completion of a one month trial period. The purchase of a TENS device is limited to once every five years. NMES/TENS Garments Prior authorization requests for the purchase of the NMES/TENS conductive garments must include supporting documentation that shows the following: The garment has been prescribed by a physician for use in delivering covered NMES/TENS treatment. The client has successfully completed a one month trial period. The conductive garment is necessary for one of the following reasons: There is such a large area or so many sites to be stimulated that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires. The areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires. The client has a documented medical condition, such as skin problems that contraindicates the application of conventional electrodes, adhesive tapes, and lead wires. The rental of the NMES/TENS garment is not a benefit during the trial rental period unless the client has a documented skin problem before the start of the trial period; and the Department of State Health Services (DSHS) or its designee is satisfied that use of such an item is medically necessary for the client.

4 NMES/TENS Supplies Ssupply codes 9-A4556, 9-A4557, and 9-A4595 may be reimbursed with documentation of a client-owned device. Additional documentation, such as the purchase date, serial number, and purchasing entity of the device, may be required. Supplies for purchased devices are limited as follows: Procedure code 9-A4556 is limited to 15 per month. Procedure code 9-A4557 is limited to 2 per month. Procedure code 9-A4595 is limited to 1 per month. The purchase of a NMES/TENS is limited to once every five years. Reimbursement for the rental of supplies for NMES/TENS is payable separately but will only be considered during the same request as the rental of the device. Likewise, the purchase of supplies for NMES/TENS may only be considered for reimbursement when the purchase of the device is also being requested. The physician or physical therapist who provides the services may furnish the equipment necessary for assessment. When the physician or physical therapist advises the client to rent the TENS from a supplier during the trial period rather than supplying it, program payment may be made for the rental of the TENS as well as for the services of the physician or physical therapist who is evaluating its use. However, the combined program payment that is made for the physician's or physical therapist's services and the rental of the stimulator from a supplier must not exceed the amount which would be payable for the total service, including the stimulator, furnished by the physician or physical therapist alone. Percutaneous Electrical Nerve Stimulation (PENS) PENS therapy and electrodes are a benefit of the CSHCN Services Program. PENS is a diagnostic service and may be reimbursed for a one month trial to determine if an implantable device is needed. PENS services do not require prior authorization for clients who meet the following criteria: PENS services are billed with one of the following diagnosis codes: 3320, 3331, 33821, 33828, 33829, 3383, 3501, 3502, 35571, 3359, 7220, 7230, 72400, 72401, 72402, 72409, 7249, 7292, 99760, or Treatment with TENS failed or was contraindicated for the client. PENS procedures may be reimbursed using procedure codes 2/8/F-64553, 2/F-64555, and 2/8/F PENS may be reimbursed for a one-month trial period. The medical necessity for diagnostic services that are furnished beyond the first month must be documented, including the rationale for not considering an implantable device. Because PENS is an office or outpatient therapy, the rental or purchase of the PENS devices, accessories, and supplies is not a benefit of the CSHCN Services Program.

5 Dorsal Column Neurostimulation (DCN) DCN electrode implantation and the purchase of the DCN device is a benefit of the CSHCN Services Program when medically necessary. Prior authorization is not required for the implantation and purchase of a device for DCN with the following diagnosis codes: Diagnosis Codes DCN procedures may be reimbursed using the procedure codes 2/F-63650, 2/8/F , and 2/8/F DCN devices may be reimbursed using the following procedure codes listed in the table below. Only one similar device code may be reimbursed per date of service for any provider. 9/J-E0740 9/J-L8681 9/J-L8682 9/J-L8683 9/J-L8684 9/J-L8685 9/J-L8686 9/J-L8687 9/J-L8688 9/J-L8689 For more information, refer to the following sections below: Supplies for ICN, DCN, VNS, and SNS Electronic Analysis for ICN, DCN, VNS, and SNS Revision or Removal of ICN, DCN, VNS, and SNS Devices Intracranial Neurostimulation (ICN) ICN is a benefit of the CSHCN Services Program when medically necessary. The surgical implantation, revision, and removal of intracranial deep brain stimulators (DBS) are a benefit for the relief of chronic intractable pain when more conservative methods, such as TENS, PENS, or pharmacological management have failed or were contraindicated. ICN is also a benefit for the treatment of intractable tremors due to idiopathic Parkinson s disease or essential tremors. Prior authorization is not required for the implantation and purchase of a device for ICN with the following diagnosis codes: Diagnosis Codes

6 ICN procedures may be reimbursed using the following procedure codes: 2/8/F /8/F /8/F /8/F /8/F /8/F /8/F /8/F /8/F /8/F ICN devices may be reimbursed using the following procedure codes listed in the table below. Only one similar device code may be reimbursed per date of service for any provider. 9/J-E0740 9/J-L8681 9/J-L8682 9/J-L8683 9/J-L8684 9/J-L8685 9/J-L8686 9/J-L8687 9/J-L8688 9/J-L8689 For more information, refer to the following sections below: Supplies for ICN, DCN, VNS, and SNS Electronic Analysis for ICN, DCN, VNS, and SNS Revision or Removal of ICN, DCN, VNS, and SNS Devices Vagal Nerve Stimulation (VNS) The implantation, revision, programming, and removal of the VNS device is a benefit of the CSHCN Services Program for clients who have medically intractable seizures and who are not candidates for surgical intervention. VNS is not a benefit in the following cases: For the treatment of clients with an absent left vagus nerve For the treatment of clients with depression For the treatment of clients with progressive fatal or medical diseases with a poor prognosis Prior authorization is not required for VNS with diagnosis codes or Disabilities that are due to mental retardation or cerebral palsy may confound the assessment of benefits resulting from VNS. When a diagnosis of mental retardation or cerebral palsy exists, the treating physician must document in the medical record how VNS will measurably benefit the client in spite of mental retardation or cerebral palsy. VNS procedures may be reimbursed using the following procedure codes: 2/F-61885, 2/8/F-61886, 2/8/F-64553, and 2/8/F VNS devices may be reimbursed using the following procedure codes listed in the table below. Only one similar device code may be reimbursed per date of service for any provider. 9/J-E0740 9/J-L8681 9/J-L8682 9/J-L8683 9/J-L8684 9/J-L8685 9/J-L8686 9/J-L8687 9/J-L8688 9/J-L8689 For more information, refer to the following sections below:

7 Supplies for ICN, DCN, VNS, and SNS Electronic Analysis for ICN, DCN, VNS, and SNS Revision or Removal of ICN, DCN, VNS, and SNS Devices Sacral Nerve Stimulation (SNS) SNS is a benefit of the CSHCN Services Program when medically necessary for treatment of urinary retention, urinary frequency, and urinary/fecal incontinence using the following diagnosis codes: 59655, 78820, 78831, 78841, or Prior authorization is not required for SNS with diagnosis codes listed above. SNS procedures may be reimbursed using procedure 2/F-64561, 2/F-64581, and 2/8/F SNS devices may be reimbursed using the following procedure codes listed in the table below. Only one similar device code may be reimbursed per date of service for any provider. 9/J-E0740 9/J-L8681 9/J-L8682 9/J-L8683 9/J-L8684 9/J-L8685 9/J-L8686 9/J-L8687 9/J-L8688 9/J-L8689 The medical record of the client must have documentation of the following: The urinary retention, urinary frequency, and urinary/fecal incontinence are refractory to conventional therapy (documented behavioral, pharmacological, and/or surgical corrective therapy) The client is an appropriate surgical candidate such that implantation with anesthesia can occur For more information, refer to the following sections below: Supplies for ICN, DCN, VNS, and SNS Electronic Analysis for ICN, DCN, VNS, and SNS Revision or Removal of ICN, DCN, VNS, and SNS Devices Supplies for ICN, DCN, VNS, and SNS Neurostimulator supplies, including leads and electrodes, are a benefit without prior authorization only if there is documentation of a client-owned device. Additional documentation such as the purchase date, serial number, and purchasing entity of the device may be required. Supplies for ICN, DCN, VNS, and SNS Supplies (procedure codes 9-A4290 or 9-L8680) for implantable devices may be reimbursed when there is documentation of a client-owned device. Additional documentation, such as the purchase date, serial number, and purchasing entity may be required.

8 Electronic Analysis for ICN, DCN, VNS, and SNS The following procedure codes may be reimbursed for the electronic analysis of the implanted neurostimulator: Revision or Removal of ICN, DCN, VNS, and SNS Devices The revision or removal of implantable neurostimulators may be reimbursed for clients with a history of neurostimulator implantation or device purchase using the following procedure codes: Device DCN DCN ICN ICN or VNS SNS SNS 2/8/F /8/F /8/F /8/F /8/F /8/F The revision or removal of a peripheral neurostimulator used in PENS therapy may be reimbursed using procedure code 2/8/F Non-Covered Services Gastric neurostimulation (GNS) and associated equipment and supplies are not a benefit of the CSHCN Services Program. In addition, neurostimulator services for indications or diagnoses other than those outlined in this article are not a benefit.

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