Does A4560 require prior authorization?

Yes, A4560 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for A4560?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`A4560`, Neuromuscular electrical stimulator (nmes), disposable, replacement only

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For FES (Parastep) ambulatory coverage: documentation that ALL selection criteria are met, including intact lower motor units (L1 and below), joint stability and balance to bear weight, brisk muscle contraction to NMES and sensory perception sufficient for contraction, cognitive ability and motivation, independent transfers and ability to stand at least 3 minutes, adequate hand/finger function to manipulate controls, at least 6 months post recovery of SCI and restorative surgery, absence of hip/knee degenerative disease and no history of long bone fracture secondary to osteoporosis, and completion of at least 32 physical therapy training sessions with the device over a 3-month period.

For NMES for disuse atrophy: documentation that nerve supply to the muscle is intact and the disuse atrophy is due to listed non-neurological causes (contractures due to burn scarring; failure to respond to physical therapy after major knee surgery; failure to respond to physical therapy after casting/splinting; or recent hip replacement prior to initiation of physical therapy), and documentation of failure to respond to appropriate physical therapy when required.

For form‑fitting conductive garments: prescription by a physician; evidence device is FDA‑market approved; documentation that one of the garment criteria is met (large area/number of sites/frequency making conventional electrodes infeasible; skin problem or medical condition precluding conventional electrodes; need for stimulation beneath a cast for disuse atrophy with intact nerve supply; medical need for rehabilitation strengthening following injury with intact nerve supply).

For diaphragmatic/phrenic pacing (SCI indication): documentation of high quadriplegia at/above C-3, viable phrenic nerves, adequate diaphragm and lung function, and expectation that pacing will allow breathing without mechanical ventilator for at least 4 continuous hours/day.

Key Coverage Criteria

Functional electrical stimulation (FES) (e.g., Parastep I System) as durable medical equipment (DME) to enable members with spinal cord injury (SCI) to ambulate when ALL of the following criteria are met: Member has intact lower motor units (L1 and below) (both muscle and peripheral nerve); Member has joint stability to bear weight on upper and lower extremities, and has balance and control to maintain an upright posture independently; Member demonstrated brisk muscle contraction to neuromuscula [...]
Replacement of a FES for walking when the original FES met medical necessity criteria and is no longer under warranty and cannot be repaired.
FES / NMES to assist gait in patients with incomplete spinal cord injury.
Functional Electrical Stimulation / Neuromuscular Electrical Stimulation for Chronic Obstructive Pulmonary Disease (NMES to improve exercise capacity/rehabilitation in moderate-to-severe COPD)
Sacral Nerve Stimulation for the Treatment of Chronic Constipation and Fecal Incontinence (sacral neuromodulation for refractory constipation and fecal incontinence)
Wearable low-frequency NMES devices (e.g., geko T-3 and geko W-3 stimulating the common peroneal nerve) to increase local blood circulation, reduce edema, prevent venous thrombosis, and increase microcirculatory blood flow in lower limb with venous insufficiency and/or ischemia to support wound or tissue healing (device indications described; clinical value noted as lacking robust evidence).

7 Active Policies

ANTHEM-CG-DME-03, Neuromuscular Stimulation in the Treatment of Muscle Atrophy

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

AETNA-CPB-0677, Functional Electrical Stimulation and Neuromuscular Electrical Stimulation

BCBSIL-MED201.026, Surface Electrical Stimulation

BCBSMT-MED201.026, Surface Electrical Stimulation

BCBSNM-MED201.026, Surface Electrical Stimulation

BCBSOK-MED201.026, Surface Electrical Stimulation

`A4560`, Neuromuscular electrical stimulator (nmes), disposable, replacement only

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

A4560, Neuromuscular electrical stimulator (nmes), disposable, replacement only

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`A4560`, Neuromuscular electrical stimulator (nmes), disposable, replacement only