E0734 Medicare coverage

Local coverage indication

An external upper limb tremor stimulator of the peripheral nerves of the wrist (E0734) is covered when the beneficiary has had a clinical evaluation (in-person or via Medicare-approved telehealth) by the treating practitioner, and all of the following criteria are met (See the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related Policy Article): The beneficiary has a diagnosis of essential tremor (ET) (Refer to the Group 1 ICD-10 code list in the LCD-related Policy Article for applicable diagnoses);and, The beneficiary is 18 years or older; and, The beneficiary has no contraindications to external upper limb tremor stimulator therapy; and The external upper limb tremor stimulator is being prescribed to treat the beneficiary’s dominant upper limb; and, The severity of ET symptoms significantly impairs the beneficiary’s ability to perform dominant hand, upper-limb-related activities of daily living (ADLs) as indicated by a score of greater than or equal to 3 on the Bain & Findley Tremor ADL Scale (BF-ADL) for at least one (1) assessment item for eating, drinking, self-care, or writing (See Appendix A); and, If medically appropriate, tremor exacerbating medications (e.g., stimulants, beta agonists) have been reduced or eliminated; and, At least two (2) pharmacological treatment options for the management of ET symptoms have been either tried and failed at maximal tolerable treatment dosages (i.e., no or limited effect, intolerable side effects) or considered and ruled out (e.g., not appropriate in the context of the beneficiary’s medical history); and, External upper limb tremor stimulator therapy is being prescribed as an alternative to invasive and/or permanent surgical treatment options (e.g., deep brain stimulation, magnetic resonance guided focused ultrasound, radiosurgery). When an external upper limb tremor stimulator (E0734) is covered, the supplies and accessories (A4542) will also be covered. If all of the initial coverage criteria 1 through 8 are not met, claims for codes E0734 and A4542 will be denied as not reasonable and necessary.

Excerpt from LCD L39591 version 11, effective 04/07/2024. CMS LCD L39591.

From A59680

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. The medical records must include all of the following documentation to support initial coverage of an external upper limb tremor stimulator of the peripheral nerves of the wrist (E0734) and associated supplies (A4542): The beneficiary is 18 years or older with a diagnosis of essential tremor (ET) with symptoms affecting their dominant upper limb, and has no contraindications to external upper limb tremor stimulator therapy; and, The external upper limb tremor stimulator is being prescribed to treat severe ET symptoms in the beneficiary’s dominant upper limb that impairs their ability to perform upper-limb-related (i.e., eating, drinking, self-care, writing) activities of daily living (ADLs).

CMS source A59680

From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs

GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific

CMS article A55426