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.

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

• DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

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:

• As a component of post-operative rehabilitation in either of the following settings:
  • When muscular atrophy is present before an orthopedic intervention (i.e., repair of anterior cruciate ligament). In this setting, neuromuscular stimulation may be initiated immediately in the post-op phase as an adjunct to physical therapy;
  • When muscular atrophy develops in the post-operative period. Individuals meeting this criterion typically are participating in a physical therapy program, but have experienced complications related to the surgery, which preclude successful physical therapy. In this setting, neuromuscular stimulation may be initiated only after the development of muscle atrophy.
    
    
• As a treatment of muscular atrophy related to other medical conditions, such as disuse atrophy.
  
  
• A neuromuscular stimulator garment is considered medically necessary when:
  • There is a large area or many sites to be stimulated that use of conventional electrodes, adhesive tapes and lead wires is not feasible; or
  • The areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
  • There is a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires. 

Not Medically Necessary: 

Neuromuscular stimulation is considered not medically necessary for:

• Prevention of muscle atrophy, e.g., following an orthopedic procedure;
• Treatment of pain for various musculoskeletal conditions, including, but not limited to patellofemoral syndrome, spinal stenosis, lumbago, muscle strains/sprains;
• As a technique to increase circulation.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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. 

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. Neuromuscular stimulation (also known as neuromuscular electrical stimulation or NMES) is a technique that uses electrical currents that stimulate the motor nerves, generating muscle contractions in order to reverse muscle atrophy. When nerve innervation is intact, NMES promotes re-innervation, retards the development of disuse atrophy, relaxes muscle spasms and promotes voluntary muscle control for individuals who have lost muscle function.   The intensity and frequency of stimulation can vary based on the level of muscular function and response to treatment.

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

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. 

In another study, Palmieri-Smith and colleagues reported whether NMES is capable of improving quadriceps muscle strength and activation in women with mild and moderate knee osteoarthritis. Thirty women with radiographic, not symptomatic, 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 improvements in muscle strength were seen in the treatment group. Muscle strength were similar across both control and treatment groups. Limitations of the study were that it was not blinded and that osteoarthritis was based on radiographic evidence alone, exclusive of symptoms.

To investigate the long-term efficacy of neuromuscular electrical stimulation in enhancing motor recovery in the upper extremities of those post stroke, 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 neuromuscular electrical stimulation 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.

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. 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.  

Government Agency, Medical Society, and Other Authoritative Publications:

1. Brosseau L, Wells GA, Finestone HM, et al. Clinical practice guidelines for electrical stimulation. 2006. Available at: www.guideline.gov/summary/summary.aspx?doc_id=9918. Accessed on June 21, 2010.
2. Centers for Medicare and Medicaid Services. National Coverage Determination for Neuromuscular Electrical Stimulation (NMES). NCD #160.12. Effective April 1, 2003. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=175&ncdver=2&bc=AgAAQAAAAAAA&. Accessed on June 21, 2011.
3. Centers for Medicare and Medicaid Services. National Coverage Determination for 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: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=151&ncdver=1&bc=AgAAQAAAAAAA&   Accessed on June 21, 2011.
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 21, 2011.

Disuse Atrophy
Muscle Atrophy
Neuromuscular Stimulation