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 guideline.

Medically Necessary:

FDA approved TENS and PENS units are considered medically necessary when prescribed as a treatment for pain for those patients 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 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.

Outpatient

The following codes for treatments and procedures applicable to this guideline 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 patients' 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. 

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. 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.
3. Cameron M, Lonergan E, Lee H. Transcutaneous electrical nerve stimulation (TENS) for dementia. Cochrane Database Syst Rev. 2003; (3):CD004032.
4. Carroll D, Moore RA, McQuay HJ, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2002; (3):CD003222.
5. 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.
6. 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.
7. De Angelis C, Perrone G, Santoro G, et al. Suppression of pelvic pain during hysteroscopy with a transcutaneous electrical nerve stimulation device. Fertil Steril. 2003; 79(6):1422-1427.
8. Ghoname EA, White PF, Ahmed HE et al. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica. Pain. 1999; 83(2):193-199.
9. 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.
10. Ghoname ES, Craig WF, White PF et al. The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain. Anesth Analg. 1999; 88(4):841-846.
11. Hamza MA, Ghoname EA, White PF et al. Effect of the duration of electrical stimulation on the analgesic response in patients with low back pain. Anesthesiology. 1999; 91(6):1622-1627.
12. 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.
13. Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain. Cochrane Database Syst Rev. 2002; (2):CD003008.
14. Osiri M, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis Cochrane Database Syst Rev. 2000; (4):CD002823.
15. Pelland L, Brosseau L, Casimiro L, et al. Electrical stimulation for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2002; (2):CD003687.
16. Price CIM, Pandyan AD. Electrical stimulation for preventing and treating post-stroke shoulder pain. Cochrane Database Syst Rev. 2000; (4):CD001698.
17. Proctor ML, Smith CA, Farquhar CM, et al. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev. 2002; (1):CD002123.
18. Rakel B, Frantz R. Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain. 2003; 4(8):455-464.
19. White PF, Ghoname EA, Ahmed HE et al. The effect of montage on the analgesic response to percutaneous neuromodulation therapy. Anesth Analg. 2001; 92(2):483-487.
20. 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.
21. White PF, Craig WF, Vakharia AS et al. Percutaneous neuromodulation therapy: does the location of electrical stimulation effect the acute analgesic response? Anesth Analg. 2000; 91(4):949-954.

Government Agency, Medical Society and Other Authoritative Publications:

1. American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: a report by the American society of Anesthesiologists task force on pain management, chronic pain section. Anesthesiology. 1997; 86(4):995-1004. Available at: http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-199704000-00032.htm;jsessionid=FrpJzVhh2c8Bc5vkGjJ43QbB3dchjvjDHnT21sQyZv7QGjfG78x3!-1455700262!-949856145!8091!-1. Accessed on June 13, 2007.
2. 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.hhs.gov/mcd/index_chapter_list.asp  Accessed on June 13, 2007.
3. 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.hhs.gov/mcd/index_chapter_list.asp. Accessed on July 27, 2006.
4. 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.hhs.gov/mcd/index_chapter_list.asp. Accessed on June 13, 2007.
5. 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.hhs.gov/mcd/index_chapter_list.asp. Accessed on June 13, 2007.
6. National Guideline Clearinghouse. Persistent pain management. 2005. Available at:http://www.guideline.gov/summary/summary.aspx?doc_id=8627&nbr=004807&string=transcutaneous+AND+electrical+AND+nerve+AND+stimulation. Accessed on June 13, 2007.

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)