TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Electrical stimulation devices are covered for eligible Medical Assistance and MinnesotaCare members who meet criteria described under the Covered Services heading.

Electrical or electromagnetic devices for wound care are addressed in the Specialized Wound Treatment Therapy section of the MHCP Provider Manual. Transcutaneous electrical stimulation devices are addressed in the Transcutaneous Electrical Nerve Stimulator (TENS) section of the MHCP Provider Manual.

Covered Services

Codes: E0740, E0744, E0745, E0770, E0766

Pelvic Floor Stimulators
Pelvic floor stimulators (E0740) are covered with authorization if the following criteria are met:

· The member has a diagnosis of stress, urges or mixed incontinence; and

· The member has undergone a documented trial of pelvic muscle exercises for a period of at least six months with no significant improvement in incontinence.

Neuromuscular Stimulation for Scoliosis
Neuromuscular stimulators for scoliosis (E0744) are covered if the following criteria are met:

· The member has juvenile or adolescent single or double major idiopathic scoliosis; and

· The member is at risk for curve progression and whose curvature is between 25 and 40 degrees; or

· The member has curvature between 20 to 25 degrees and there is a documented progression of curvature of at least 5 degrees in the previous six months.

Authorization is required for excess quantities or repairs if the submitted charge is over $400.

Neuromuscular Stimulators
Neuromuscular stimulators (E0745) are covered with authorization if the following criteria are met:

· The member requires treatment for disuse muscle atrophy where nerve supply to the muscle is intact; and

· There is a non-neurological reason for the disuse atrophy.

Functional Electrical Stimulators
Upper extremity functional electrical stimulators (E0770) are covered with authorization if the following criteria are met:

· The member has upper limb paralysis due to one of the following:

· Cervical spinal cord injury; or

· Chronic upper extremity paresis due to stroke; and

· Documentation shows improvement in the supervised rehabilitation setting.

Electrical Stimulation for Cancer Treatment
Electrical stimulation devices used for cancer treatment (E0766) are covered with authorization for members with glioblastoma if the following criteria are met:

· The member has histologically confirmed (World Health Organization grade IV astrocytoma), newly diagnosed, supratentorial glioblastoma; and

· The member has received initial treatment with maximal debulking surgery when feasible, followed by chemotherapy and radiotherapy; and

· Treatment is initiated within seven weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later; and

· The member has no evidence of progression by Response Assessment in Neuro-Oncology criteria; and

· The member has a Karnofsky Performance Score of at least 70; and

· The member will use the treatment for an average of 18 hours per day.

Providers must reevaluate the member’s condition every third month of treatment for continued use. Authorization is required every three months. Documentation for subsequent requests must illustrate that the member has responded to treatment and continues to require treatment with the device.

Noncovered Services

MHCP does not cover the following:

· Pelvic floor stimulators are considered investigative for indications not listed in this policy

· Neuromuscular stimulators for scoliosis are not medically necessary for members with curvatures less than 20 degrees

· Upper extremity functional electrical stimulators for indications not listed in this policy

· Electrical stimulation devices that are not listed in this policy

· The following are considered investigative:

· Cranial electrotherapy stimulation systems (E0732) (that is, Alpha-Stim)

· Transcutaneous electrical nerve stimulators for electrical stimulation of the trigeminal nerve (E0733) (that is, Cefaly Dual Connected and Enhanced, Monarch eTNS System)

· External upper limb tremor stimulators of the peripheral nerves of the wrist (E0734) (that is, Cala Trio, Felix NeuroAI)

· Noninvasive vagus nerve stimulators (E0735) (that is, gammaCore)

· Transcutaneous tibial nerve stimulators, controlled by phone application (E0737)

· Upper extremity rehabilitation systems with microprocessor (E0738) (that is, IpsiHand)

· Rehabilitation system with interactive interface (E0739) (that is, Motus Nova’s Motus Foot and Hand)

· Electromyography biofeedback devices (E0746) (that is, Persist Treatment System, Myoxexorciser II)

· Electronic salivary reflex stimulators (E0755)

· High-peak power electromagnetic energy treatment devices (E0761) (that is, Active Knee System, Diapulse Wound Treatment System)

· Transcutaneous electrical joint stimulation devices (E0762) (that is, Jstim 1000)

· Functional neuromuscular stimulation (E0764) (that is, Parastep I System)

· FDA approved nerve stimulators for treatment of nausea and vomiting (E0765) (that is, Reliefband, PrimaBella)

· Electrical stimulation or electromagnetic wound treatment devices, not otherwise classified (E0769) (that is, Provant Therapy System)

· Electroceutical therapy for treatment of acute or chronic pain

· Functional electrical stimulators designed as ergometers (that is, RT300)

· Functional electrical stimulators for lower extremities (that is, Parastep Ambulation System, NESS L300, WalkAide)

· Inferential current simulators for use in the home (that is, RS-4i)

· Sympathetic therapy (that is, Dynatron Machine)

Implanted Neurostimulators are ordered by physicians, not durable medical equipment providers. Refer to Implanted Neurostimulators in the Physicians and Professionals section of the MHCP Provider Manual.

Authorization

Authorization is required for the following:

· Quantities over MHCP quantity limits

· Pelvic floor stimulators (E0740)

· Neuromuscular stimulators (E0745)

· Electrical stimulation devices for cancer treatment (E0766)

· Functional electrical stimulators for the upper extremities (E0770)

· Repairs to neuromuscular stimulators for scoliosis if the submitted charge is over $400

Submit authorization request and required documentation to the Medical Review Agent.

Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements, billing frequencies, and quantity limits by HCPCS code.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Bill electrical stimulation devices using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· Enter the ordering provider in the Other Provider Types section of the Provider tab of the MN–ITS Interactive Claim.

· If the member has Medicare, MHCP will pay only the deductible or coinsurance on any item for which Medicare made payment, regardless of any MHCP prior authorization.

· Shipping, delivery and set-up costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the member.

· When billing labor for repairs, specify the number of units and the hourly rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.

· When billing for items approved on a prior authorization, make sure the HCPCS codes, modifiers and descriptions on the claim match the same information on the prior authorization. Enter the authorization number in the authorization field for each line.

· Submit the usual and customary charge for each line, not the approved amount from the authorization letter. Payment will be the balance of the lesser of the billed amount or the approved amount after any primary or secondary payers have made payment.

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