Clinical UM Guideline
|Subject:||Electrical Nerve Stimulation, Transcutaneous, Percutaneous|
|Guideline #:||CG-DME-04||Current Effective Date:||10/14/2014|
|Status:||Reviewed||Last Review Date:||08/14/2014|
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:
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:
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.
|A4595||Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)|
|A4630||Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient|
|E0720||Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation|
|E0730||Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation|
|E0731||Form-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]|
|ICD-10 Diagnosis||[For dates of service on or after10/01/2015]|
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.
Peer Reviewed Publications:
Government Agency, Medical Society and Other Authoritative Publications:
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)
|Reviewed||08/14/2014||Medical Policy & Technology Assessment (MPTAC) review. Updated Rationale and References.|
|Reviewed||08/08/2013||MPTAC review. Updated References.|
|Reviewed||08/03/2012||MPTAC review. No change to criteria. Discussion/General Information and References updated.|
|Reviewed||08/18/2011||MPTAC review. No change to criteria. Coding and References updated.|
|Reviewed||08/19/2010||MPTAC review. No change to criteria. Discussion and References updated.|
|Reviewed||08/27/2009||MPTAC review. References updated.|
|Reviewed||08/28/2008||MPTAC review. References updated.|
|Reviewed||08/23/2007||MPTAC review. References updated.|
|01/01/2007||Updated coding section with 01/01/2007 CPT/HCPCS changes.|
|Revised||09/14/2006||MPTAC review. Revision included addressing TENS garment. References updated.|
|11/22/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||09/22/2005||MPTAC review. Revisions based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|WellPoint Health Networks, Inc.||04/28/2005||5.10.01||Electrical Nerve Stimulation, Transcutaneous, Percutaneous|