Clinical UM Guideline


Subject:Electrical Nerve Stimulation, Transcutaneous, Percutaneous
Guideline #:  CG-DME-04Current Effective Date:  10/14/2014
Status:ReviewedLast Review Date:  08/14/2014

Description

This document addresses transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS). Electrical stimulation is a method used to treat pain through electrodes placed on or just beneath the skin that send small electrical impulses to underlying sensory nerve fibers to modify pain perception. It is theorized that electrical stimulation of the nerve fibers, applied near the segment of the spinal cord, blocks  pain signals from reaching the brain. Electrical stimulation is also theorized to reduce inflammation and swelling, and relaxes muscle fibers by releasing endorphins in the brain, which act like analgesics. The use of acupuncture with electrical stimulation is not addressed in this document.

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

Clinical Indications

Medically Necessary:

FDA approved TENS and PENS units are considered medically necessary when prescribed as a treatment for pain for those who have not responded to other modalities, in the following situations:

 An FDA approved TENS garment, when prescribed, is considered medically necessary when:

Coding

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.

HCPCS 
A4595 Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
A4630Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient
E0720Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0731Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
 All diagnoses
Discussion/General Information

TENS uses a battery-operated device that applies electrical stimulation at the site of pain by wired electrodes that are taped to the surface of the skin. TENS can also be delivered through the use of a form-fitting conductive garment (e.g., a garment with conductive fibers that are separated from the individuals' skin by layers of fabric). This garment is applied when a condition exists that precludes conventional TENS electrode placement. TENS has been used to relieve pain related to musculoskeletal conditions, or pain associated with active or post-trauma injury. 

PENS is similar in concept to TENS, but differs in that needle electrodes are implanted just beneath the skin instead of being taped to the surface of the skin. It is important to distinguish PENS from acupuncture with electrical stimulation. In electrical acupuncture, needle electrodes are also inserted just below the skin, but they are not necessarily inserted at the site of pain, but placed according to acupuncture meridians, a concept of Chinese medicine.

There are many published reports regarding the use of TENS and PENS for various types of conditions such as low back pain (LBP), myofascial and arthritic pain, sympathetically mediated pain, neurogenic pain, visceral pain, diabetic neuropathy and postsurgical pain. While randomized controlled trials (RCTs) have focused on both TENS and PENS, all of the currently available studies have methodological flaws that limit interpretation, including inadequate blinding, lack of reporting of drop outs, lack of reporting of stimulation variables, and lack of proper outcome measures. However, it is recognized that both TENS and PENS are widely accepted in the physician community as a treatment of a variety of etiologies of pain.

The American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) support the use of TENS in their revised guideline recommending that "TENS should be used as a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g. neck and phantom limb pain)" (ASA/ASRA, 2010).

Current published studies of PENS for neuropathic pain (Raphael, 2011) and TENS for gastric dysmotility with slow transit constipation (Yik, 2011), have shown limited success, but require larger studies to demonstrate clinical efficacy.

References

Peer Reviewed Publications:

  1. Ahmed HE, White PF, Craig WF, et al. Use of percutaneous electrical nerve stimulation (PENS) in the short-term management of headache. Headache. 2000; 40(4):311-315.
  2. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil. 2002; 16(7):749-760.
  3. Cheing GL, Tsui AY, Lo SK, et al. Optimal stimulation duration of TENS in the management of osteoarthritic knee pain. J Rehabil Med. 2003; 35(2):62-68.
  4. Ghoname EA, Craig WF, White PF et al. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. JAMA. 1999; 281(9):818-823.                           
  5. Miller L, Mattison P, Paul L, Wood L. The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis. Mult Scler. 2007; 13(4):527-533. 
  6. Raphael JH, Raheem TA, Southall JL, et al. Randomized double-blind sham-controlled crossover study of short-term effect of percutaneous electrical nerve stimulation in neuropathic pain. Pain Med. 2011; 12(10):1515-1522.
  7. Rakel B, Frantz R. Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain. 2003; 4(8):455-464.
  8. Solak O, Turna A, Pekcolaklar A, et al. Transcutaneous electric nerve stimulation for the treatment of postthoracotomy pain: a randomized prospective study. Thorac Cardiovasc Surg. 2007; 55(3):182-185.
  9. Weiner DK, Perera S, Rudy TE, et al. Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial. Pain. 2008; 140(2):344-357.
  10. Weiner DK, Rudy TE, Glick RM, et al. Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain in older adults. J Am Geriatr Soc. 2003; 51(5):599-608.
  11. Yik YI, Clarke MC, Catto-Smith AG, et al. Slow-transit constipation with concurrent upper gastrointestinal dysmotility and its response to transcutaneous electrical stimulation. Pediatr Surg Int. 2011; 27(7):705-711.
  12. Yokoyama M, Sun X, Oku S, et al. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004; 98(6):1552-1556. 

Government Agency, Medical Society and Other Authoritative Publications:

  1. American Academy of Neurology (AAN). Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review). Neurology. 2010; 74:173–176.
  2. American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA). Practice guidelines for chronic pain management. Anesthesiology. 2010; 112(4):810-833. 
  3. Brosseau L, Yonge KA, Robinson V, et al. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database Syst Rev. 2003;(3):CD004287.                                
  4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP). NCD #160.27. Effective June 8, 2012. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 11, 2014.
  5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Transcutaneous electrical nerve stimulation (TENS) for acute post-operative pain. NCD #10.2. Effective August 7, 1995. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 16, 2014.
  6. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Transcutaneous electrical nerve stimulators (TENS). NCD #280.13. Effective August 7, 1995. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 16, 2014.
  7. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Supplies used in the delivery of transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES). #160.13. Effective July 14, 1988. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 16, 2014.
  8. Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-491.
  9. Hooten WM, Timming R, Belgrade M, et al. Assessment and management of chronic pain. Institute for Clinical Systems Improvement (ICSI). 2013. Available at: https://www.icsi.org/_asset/4kkxom/ChronicPainES.pdf.  Accessed on June 16, 2014.
  10. Khadilkar A, Milne S, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain. Cochrane Database Syst Rev. 2005; (3):CD003008.
  11. Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013;(8):CD004251.
  12. National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance 450. Percutaneous electrical nerve stimulation for refractory neuropathic pain. March 2013. Available at: http://www.nice.org.uk/nicemedia/live/13961/63356/63356.pdf. Accessed on June 16, 2014.
  13. Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008;(3):CD003222.
  14. Rutjes AWS, Nüesch E, Sterchi R, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis Cochrane Database Syst Rev. 2009;(4):CD002823.
  15. Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009;(2):CD006142.
Index

Electrical Nerve Stimulation, Transcutaneous and Percutaneous
PENS (Percutaneous Electrical Nerve Stimulation)
Percutaneous Electrical Nerve Stimulation (PENS)
TENS (Transcutaneous Electrical Nerve Stimulation)
Transcutaneous Electrical Nerve Stimulation (TENS)

History
StatusDateAction
Reviewed08/14/2014Medical Policy & Technology Assessment (MPTAC) review. Updated Rationale and References.
Reviewed08/08/2013MPTAC review. Updated References.
Reviewed08/03/2012MPTAC review. No change to criteria. Discussion/General Information and References updated.
Reviewed08/18/2011MPTAC review. No change to criteria. Coding and References updated.
Reviewed08/19/2010MPTAC review. No change to criteria. Discussion and References updated.
Reviewed08/27/2009MPTAC review. References updated.
Reviewed08/28/2008MPTAC review. References updated.
Reviewed08/23/2007MPTAC review. References updated.
 01/01/2007Updated coding section with 01/01/2007 CPT/HCPCS changes.
Revised09/14/2006MPTAC review. Revision included addressing TENS garment. References updated.
 11/22/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised09/22/2005MPTAC review. Revisions based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc. None 
Anthem BCBS None 
WellPoint Health Networks, Inc.04/28/20055.10.01Electrical Nerve Stimulation, Transcutaneous, Percutaneous