Does E0764 require prior authorization?

Yes, E0764 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`E0764`, Functional neuromuscular stimulation, transcutaneous stimulation of sequential

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
Record of prior conservative treatments tried and failed (e.g., trials of oral antispasmodics such as baclofen, phenol injections, botulinum toxin injections, physical therapy, bracing) including dates and responses.
Assessment documenting ambulatory potential and intrinsic lower extremity motor power (for SPR/SDR: documentation that impairment is due to spasticity rather than profound weakness), and patient/caregiver capacity and motivation to participate in post-operative rehabilitation.

Key Coverage Criteria

SPR/SDR in children with CP when there is demonstrated limitation in ambulation primarily due to spasticity and not due to intrinsic muscle weakness.
SPR/SDR for children who have tried and failed conservative medical management for spasticity (including oral baclofen or other muscle relaxants, phenol injections, physical therapy, bracing, orthopedic surgery) and who have capacity and motivation to participate in post-operative rehabilitation.
SPR/SDR considered optimal for children aged approximately 2 to 6 years (children in this age range are described as optimal candidates).
Selective tibial nerve neurotomy (selective neurotomy) as a surgical option to treat focal spastic equinovarus foot in adults (post-stroke / hemiplegic patients) — shown to reduce ankle stiffness and impairments associated with spastic equinovarus foot.
Selective peripheral neurotomy / microsurgical selective peripheral neurotomy for treatment of focal spasticity (upper or lower limb) where focal surgical denervation is appropriate.
Selective percutaneous myofascial lengthening (SPML) for release of tight myofascial/tendon bands (e.g., hip adductors, hamstrings, gastrocnemius/Achilles) in children with spastic CP when primary contracture interferes with walking, sitting, or causes joint subluxation.

8 Active Policies

ANTHEM-DME.00022, Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

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

UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

AETNA-CPB-0362, Spasticity Management

AMBETTER-CP.MP.48, Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES)

UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

SUREST-POL-SUREST-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

UHCMA-POL-UHC_MA-electrical-ultrasonic-stimulators, Electrical Stimulators

`E0764`, Functional neuromuscular stimulation, transcutaneous stimulation of sequential

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

E0764, Functional neuromuscular stimulation, transcutaneous stimulation of sequential

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`E0764`, Functional neuromuscular stimulation, transcutaneous stimulation of sequential