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 close to a segment of the spinal cord blocks the pain signals from reaching the brain or that electrical stimulation reduces inflammation, swelling and relaxes muscle fibers by releasing endorphins in the brain which act like analgesics. Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) are considered in this document.

Note: Please see the following related document(s) for additional information:
CG-ANC-03 Acupuncture

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:

• Pain related to musculoskeletal conditions; or
• Pain associated with active or post trauma injury. 

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

• There is large area or many sites to be stimulated such that use of conventional electrodes, adhesive tapes and lead wires is not feasible; or
• The areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
• There is a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires.

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.

Transcutaneous electrical nerve stimulation (TENS) uses a battery operated device that applies electrical stimulation at the site of the pain by wired electrodes that are taped to the surface of the skin. TENS can also be delivered by a form-fitting conductive garment (e.g., a garment with conductive fibers which are separated from the individuals' skin by layers of fabric) and is used 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. 

Percutaneous electrical nerve stimulation (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.

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 trials have focused on both TENS and PENS, all of the studies have methodologic flaws limiting interpretation, including adequate blinding, drop outs, stimulation variables and 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).

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, 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.
3. 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.                              
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. Hamza MA, White PF, Craig WF, et al. Percutaneous electrical nerve stimulation: a novel analgesic therapy for diabetic neuropathic pain. Diabetes Care. 2000; 23(3):365-370.
6. 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. 
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, 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.
10. 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.
11. 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. National Coverage Determination for Assessing Patient's Suitability for Electrical Nerve Stimulation. NCD #160.7.1. Effective August 7, 1995. Available at: http://www.cms.gov/medicare-coverage-database/indexes/ncd-by-chapter-and-section-index.aspx?bc=AgAAAAAAAAAA&   Accessed on June 2, 2011.
5. Centers for Medicare and Medicaid Services. National Coverage Determination for 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/details/ncd-details.aspx?NCDId=145&ncdver=1&bc=AgAAQAAAAAAA& . Accessed on June 2, 2011.
6. Centers for Medicare and Medicaid Services. National Coverage Determination for Transcutaneous Electrical Nerve Stimulators (TENS). NCD #280.13. Effective August 7, 1995. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=273&ncdver=1&bc=AgAAQAAAAAAA& . Accessed on June 2, 2011.
7. Centers for Medicare and Medicaid Services. National Coverage Determination for 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/details/ncd-details.aspx?NCDId=151&ncdver=1&bc=AgAAQAAAAAAA& . Accessed on June 27, 2010.
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):478-91.
9. 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
10. Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008; (3):CD003222.
11. Rutjes AWS, Nüesch E, Sterchi R, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis Cochrane Database Syst Rev. 2009; (4):CD002823.
12. Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database  Syst Rev. 2009; (2):CD006142.

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)