Clinical UM Guideline


Subject:Neuromuscular Stimulation in the Treatment of Muscle Atrophy
Guideline #:  CG-DME-03Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:  08/08/2013

Description

Neuromuscular stimulation (also known as neuromuscular electrical stimulation or NMES) is the application of electrical stimulation that is used for the treatment of muscular atrophy when the nerve supply to the muscle is intact.

When subjected to insufficient exercise, muscles atrophy, resulting in a loss of strength and mass. This process may occur as a result of immobilizing limbs after injury or surgery. NMES stimulates the motor nerves with electrical currents generating muscle contractions in order to reverse muscle atrophy. When nerve innervation is intact, NMES promotes re-innervation and retards the development of disuse atrophy, relaxes muscle spasms and promotes voluntary muscle control. The intensity and frequency of stimulation can vary based on the level of muscular function and response to treatment.

NMES differs from transcutaneous or percutaneous electrical nerve stimulation (TENS, PENS), in that NMES stimulation is directed to the motor nerves and TENS/PENS is directed to the sensory nerves.

 Note: Please see the following related document(s) for additional information:

Clinical Indications

Medically Necessary:

FDA approved neuromuscular stimulator devices are considered medically necessary when prescribed for the following indications when muscular atrophy is present in the setting of an intact nerve supply to the muscle, including brain, spinal cord and peripheral nerves:

Not Medically Necessary: 

Neuromuscular stimulation is considered not medically necessary for:

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

HCPCS 
E0731Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
E0745Neuromuscular stimulator, electronic shock unit
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
Discussion/General Information

To assess the effectiveness of NMES as a means of improving quadriceps strength before and after total knee replacement, Monaghan and colleagues (2010) conducted a review of the available literature. Two studies comparing NMES and exercise and exercise alone pre and post op were found and included in the review. The two studies had no significant differences reported for maximum voluntary isometric torque or endurance between the NMES group and the control group. In one study, there was significantly better quadriceps muscle activation in the exercise and neuromuscular stimulation group compared with the exercise group alone. This difference was significant at the 6 weeks but not at 12 weeks. Due to the absence of raw data scores, further analysis of both studies was not possible. Both studies carried a high risk of bias. The authors concluded that the available studies for this review preclude any conclusions for the clinical efficacy and safety of NMES for quadriceps strengthening pre and post op total knee replacement.   

Stevens-Lapsley and colleagues (2012) published results from a clinical trial studying initiation of quadriceps muscle NMES 48 hours post total knee replacement as an adjunct to standard rehabilitation. Sixty-six subjects were randomly assigned to the control group (standard rehabilitation) or the treatment group, standard rehabilitation plus quadriceps NMES. Muscle strength, functional performance, and self-report measures data were collected pre and post surgery and at 3.5, 6.5, 13, 26, and 52 weeks after total knee replacement. Significant improvements in the NMES group were seen post op at 3.5 weeks for quadriceps and hamstring muscle strength, functional performance, knee extension and active range of motion. At 52 weeks, the differences between groups were attenuated, but improvements with NMES were still significant for quadriceps and hamstring muscle strength, functional performance, and some self-report measures. For this small study, the authors concluded that early addition of NMES effectively reduced the loss of quadriceps muscle strength and improved functional performance following total knee replacement. The effects were most pronounced and clinically meaningful within the first month after surgery, but persisted through 1 year after surgery. The authors acknowledged study limitations, in that the treatment volume was not matched for both study arms; NMES was added to the standard of care treatment. Also, testers were not blinded during testing, but used standardized scripts to avoid bias. The authors also stated that further research focused on early intervention after total knee replacement is warranted.

Broderick and colleagues (2010) studied the impact of bedrest on decreased circulation. They proposed that lack of activation of the calf muscle pump during this resting period gives rise to venous stasis which may lead to deep vein thrombosis (DVT) development. A pilot study was conducted to investigate the effects that 4 hours of bed rest had on the lower limb hemodynamics of healthy subjects and to what extent, if any, electrically elicited contractions of the calf muscles can alleviate these effects. Measurements included popliteal vein blood flow and heart rate in 2 groups—one without stimulation and one with stimulation. The resting group without stimulation experienced a significant decline in popliteal venous blood flow of approximately 47% with approximately 13% decrease in heart rate while the stimulated group maintained a significantly higher venous blood flow and heart rate. The authors proposed that electrically elicited calf muscle contractions significantly improve lower limb blood flow and can alleviate some debilitating effects of bed rest. Further randomized studies are needed to substantiate this pilot study.

Palmieri-Smith and colleagues (2010) studied the impact of NMES on quadriceps muscle strength and activation in women with mild and moderate knee osteoarthritis. Thirty women with radiographic, evidence of knee osteoarthritis were randomized into 2 groups—treatment and no treatment. Those in the intervention group received NMES 3 times a week for 4 weeks. The effects of NMES on quadriceps muscle strength were evaluated at one and twelve weeks after treatment completion. No improvement in muscle strength was seen in the treatment group.

To investigate the long-term efficacy of neuromuscular electrical stimulation in enhancing motor recovery in the upper extremities of post stroke individuals, Lin and colleagues (2011) conducted a study of 46 stroke subjects randomized into a NMES treatment group or a control group. All subjects participated in a standard rehabilitation program. Those in the NMES group received neuromuscular electrical stimulation for 30 min, 5 days a week for 3 weeks. Measurements were recorded before treatment, at the 2nd and 3rd week of treatment and 1, 3 and 6 months after treatment ended. The Modified Ashworth Scale for spasticity, the upper extremity section of the Fugl-Meyer motor assessment, and the Modified Barthel Index were used to assess the results. Significant improvements were found in both groups and persisted 1 month after treatment had been discontinued. At 3 and 6 months after treatment was discontinued the average scores in the NMES group were significantly better than those in the control group. The authors acknowledged the limitations of the study were its small size and lack of a sham group with blinding. They concluded that additional studies, using similar stimulation protocols with a larger sample, are needed to gain further insight into the value of NMES to restore functionality after stroke.

A literature review by Maddocks and colleagues (2013) reported on 11 studies involving a total of 218 participants with chronic obstructive pulmonary disease (COPD), chronic heart failure and thoracic cancer. The primary objective evaluated the effectiveness of NMES for improving muscle strength, while secondary measures included the safety of NMES, muscle mass, exercise capacity, breathlessness and health-related quality of life. The authors concluded that NMES appears to be effective in leading to improvements in leg muscle strength and the ability to exercise, however, this needs to be confirmed in larger trials and additional research is needed to help determine the effects on the secondary objectives.

Clinical trials for NMES are in progress for other applications such as muscle atrophy secondary to severe COPD, muscle strengthening for cerebral palsy, quadriceps strengthening pre and post total knee replacement and reversing muscle atrophy in rheumatoid arthritis as well as the use of NMES to improve circulation.

References

Peer Reviewed Publications:

  1. Broderick BJ, O'Briain DE, Breen PP, et al. A pilot evaluation of a neuromuscular electrical stimulation (NMES) based methodology for the prevention of venous stasis during bed rest. Med Eng Phys. 2010; 32(4):349-355.
  2. Hsu SS, Hu MH, Wang YH, et al. Dose-response relation between neuromuscular electrical stimulation and upper-extremity function in patients with stroke. Stroke. 2010; 41(4):821-824. 
  3. Lin Z, Yan T. Long-term effectiveness of neuromuscular electrical stimulation for promoting motor recovery of the upper extremity after stroke. J Rehabil Med. 2011; 43(6):506-510.
  4. Palmieri-Smith RM, Thomas AC, Karvonen-Gutierrez C, Sowers M. A clinical trial of neuromuscular electrical stimulation in improving quadriceps muscle strength and activation among women with mild and moderate osteoarthritis. Phys Ther. 2010; 90(10):1441-1452.
  5.  Stevens-Lapsley JE, Balter JE, Wolfe P, et al. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther. 2012; 92(2):210-226.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Neuromuscular electrical stimulation (NMES). NCD #160.12. Effective October 1, 2006. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 5, 2013.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Supplies used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES). NCD #160.13. Effective July 14, 1988. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 6, 2013.
  3. Maddocks M, Gao W, Higginson IJ, Wilcock A. Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev, 2013; (1):CD009419.
  4. Monaghan B, Caulfield B, O'Mathúna DP. Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement. Cochrane Database Syst Rev, 2010; (1):CD007177.
  5. National Institutes of Health (NIH). Clinical Trials: Neuromuscular Electrical Stimulation (NMES). Available at: http://clinicaltrials.gov/ct2/results?term=neuromuscular+electrical+stimulation+%28NMES%29. Accessed on June 6, 2013.
Index

Disuse Atrophy
Muscle Atrophy
Neuromuscular Stimulation

History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References.
Reviewed08/09/2012MPTAC review. No change to criteria. Discussion/General Information and References updated.
Reviewed08/18/2011MPTAC review. No change to criteria. Coding, Discussion/General Information and References updated.
Reviewed08/19/2010MPTAC review. No change to criteria. Place of Service deleted. Background and References updated.
Reviewed08/27/2009MPTAC review. References updated.
Reviewed08/28/2008MPTAC review. References updated.
Reviewed08/23/2007MPTAC review. References updated.
Revised09/14/2006MPTAC review. Revision addressed use of neuromuscular stimulation garment. References updated.
Reviewed06/08/2006MPTAC review. References and coding updated.
 11/22/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised07/14/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.N/A  
Anthem BCBSN/A  
WellPoint Health Networks, Inc.06/24/2004NoneNeuromuscular Stimulation in the Treatment of Muscle Atrophy