Transcutaneous Electrical Nerve Stimulator (TENS)

POLICY NUMBER

L.1.01.408

DESCRIPTION

Transcutaneous electrical nerve stimulator (TENS) is an electronic device that applies electrical stimulation to the surface of the skin at the site of pain and has been used to relieve chronic intractable pain, post-surgical pain, and pain associated with active or post-trauma injury unresponsive to other standard pain therapies. TENS has also been used to treat dementia by altering neurotransmitter activity and increasing brain activity that is thought to reduce neural degeneration and stimulate regenerative processes.

TENS consist of an electrical pulse generator, usually battery operated, connected by wire to two or more electrodes, which are applied to the surface of the skin at the site of the pain.

Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves that is designed to stimulate the sympathetic nervous system in an effort to "normalize" the autonomic nervous system and alleviate chronic pain. Unlike TENS or inferential electrical stimulation, sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain.

See separate medical policies for  Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy  and Neuromuscular Electrical Stimulation .

POLICY

Transcutaneous electrical nerve stimulation (TENS) is considered medically necessary for chronic intractable back pain (lumbar, cervical, or thoracic), where other modalities have failed.   

• Rental of the TENS for a one month trial period to permit the physician to study the effects and benefits is required. After the one-month trial period, a re-certification will be required from the prescribing physician verifying significant therapeutic improvement in the Subscriber's condition before continued benefits can be provided. In addition, the physician must document the required time period for continued use.

• A one-month supply of related supplies (tape patches, leads, electrodes, and gel) are included with the monthly rental or purchase of a TENS. Benefits for Neuro-Aid (pre-gel, disposable electrode pads) are covered only when medically necessary due to Subscriber being allergic to tape. When Neuro-Aid is covered, benefits are payable as a medical supply separate from the rental or purchase of the TENS.

Transcutaneous electrical nerve stimulation (TENS) is considered investigational for the management of chronic intractable or acute postoperative pain.

The use of TENS to relieve pain of labor and vaginal delivery is considered investigational.

The use of TENS for any other condition, including but not limited to the treatment of dementia and prevention of migraine headaches, is considered investigational.

Sympathetic Therapy, which is delivered using the Dynatron STS and Dynatron STS Rx device, is considered investigational.

POLICY EXCEPTIONS

For FEP subscribers, continued use of transcutaneous electrical nerve stimulation (TENS) may be considered medically necessary for treatment of refractory chronic pain (e.g., chronic musculoskeletal or neuropathic pain) that causes significant disruption of function when efficacy has been demonstrated in an initial therapeutic trial and compliance has been demonstrated in the therapeutic trial with the device used on a regular basis (e.g., daily or near daily use) throughout the trial period. Refractory chronic pain is defined in this policy as pain that causes significant disruption of function and has not responded to at least 3 months of conservative therapy, including nonsteroidal anti-inflammatory medications, ice, rest, and/or physical therapy.

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

8/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, CPT code 64550 added, ICD-9 procedure code 93.39 added, HCPCS E0720-E0749, K0118 added.

2/11/2002: Investigational definition added.

2/25/2002: Sources, Code Reference, and Place of Service sections updated, non-covered table added Code Reference section, CPT code 97014, 97032 with notes: “This is non-covered when used to bill for sympathetic therapy.” and “When sympathetic therapy is administered in the physician's office, CPT code 97014 or 97032 may be used, which describes unattended and attended electrical stimulation therapy, respectively. These CPT codes are not specific for sympathetic therapy, and thus when offered in the office or clinic, based on CPT code alone, sympathetic therapy cannot be distinguished from other types of electrical stimulation” added non-covered codes, HCPCS A9900 with note “There is no HCPCS code that explicitly describes sympathetic therapy. HCPCS A9900 is non-covered when used to bill for sympathetic therapy” added non-covered codes, HCPCS E1399 with notes “There is no HCPCS code that explicitly describes sympathetic therapy. The appropriate code to report this service is E1399.” and “E0730 is sometimes used to report sympathetic therapy. E0730 is non-covered when used to bill for sympathetic therapy” added non-covered codes.

5/8/2002: Type of Service and Place of Service deleted.

5/29/2002: Code Reference section updated, ICD-9 diagnosis code 724.8 added covered codes, HCPCS A4595, A4630 added covered codes, HCPCS K0118 and E0749 deleted covered codes.

3/31/2005: Reviewed by MPAC, clarification of back pain to include lumbar, cervical, or thoracic, Sources updated.

6/6/2005: Hyperlink Neuromuscular Electrical Stimulation (NMES) added Description section, Code Reference section updated, ICD-9 procedure code 93.39 deleted, ICD-9 diagnosis code 720.0, 720.1, 720.2, 720.81, 720.89, 720.9, 721.0, 721.1, 721.2, 721.3, 721.4, 721.42, 721.5, 721.6, 721.7, 721.8, 721.90, 721.91, 722.0, 722.10, 722.11, 722.2, 722.30, 722.31, 722.32, 722.39, 722.4, 722.51, 722.52, 722.6, 722.70, 722.71, 722.72, 722.73, 722.80, 722.81, 722.82, 722.83, 722.90, 722.91, 722.92, 722.93, 723.0, 723.1, 723.2, 723.3, 723.4, 723.5, 723.6, 723.7, 723.8, 723.9, 724.00, 724.01, 724.02, 724.09, 724.1, 724.2, 724.3, 724.4, 724.5, 724.9 added covered codes, HCPCS code E0740, E0744, E0745, E0746, E0747, E0748 deleted covered codes, CPT code 97014, 97032 deleted non-covered codes, CPT code 97799 with note: “When sympathetic therapy is administered in the physician’s office, CPT code 97014 or 97032 may be used, which describes unattended and attended electrical stimulation therapy, respectively. These CPT codes are not specific for sympathetic therapy, and thus should not be used to report this service. Code 97799 is the appropriate code to use to report this service.” added, HCPCS E1399 note “E0730 is sometimes used to report sympathetic therapy. E0730 is non-covered when used to bill for sympathetic therapy (added 2-25-2002)” deleted non-covered codes.

3/15/2006: Coding updated: HCPCS 2006 revisions added to policy.

4/11/2006: Policy reviewed, no changes.

9/20/2006: Coding updated. HCPCS 2006 revisions added to policy.

12/21/2006: Policy reviewed, sympathetic therapy description added, policy unchanged.

3/28/2007: Policy reviewed, dementia description and policy statement added.

12/30/2010: Policy statement and description unchanged. Policy Exception section updated regarding coverage for FEP subscribers.

11/10/2011: Policy reviewed; no changes.

05/07/2012: Removed outdated reference, www.chronicpainrx.com, from the Sources section.

09/27/2012: Policy reviewed; no changes.

10/23/2013: Policy reviewed; no changes.

07/11/2014: Investigational policy statement revised to include prevention of migraine headaches.

09/01/2015: Code Reference section updated for ICD-10. Updated the code description of A4595.

04/26/2016: Policy Guidelines updated to add medically necessary and investigative definitions.

05/31/2016: Policy number L.1.01.408 added.

09/29/2017: Code Reference section updated to add new ICD-10 diagnosis codes M48.061 and M48.062. Effective 10/01/2017.

12/22/2017: Code Reference section updated to revise description for CPT code 64550 effective 01/01/2018.

12/27/2018: Code Reference section updated to make note of deleted CPT code 64550, effective 12/31/2018. Removed deleted ICD-10 diagnosis code M48.06.

03/30/2021: Code Reference section updated to add new HCPCS codes K1016 and K1017, effective 04/01/2021. Removed deleted CPT code 64550.

10/01/2021: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add new HCPCS codes K1023 and new ICD-10 diagnosis codes M54.50, M54.51, and M54.59 effective 10/01/2021.

08/17/2022: Code Reference section updated to add HCPCS codes K1018 and K1019. Corrected typographical error to change K0123 to K1023.

09/30/2022: Code Reference section updated to revise description for HCPCS code K1019, effective 10/01/2022.

03/31/2023: Code Reference section updated to add HCPCS code A4560. Revised code description for HCPCS code K1019. Effective 04/01/2023.

12/21/2023: Code Reference section updated to add new 2024 HCPCS codes A4541, A4542, E0733, and E0734, effective 01/01/2024.

03/27/2024: Code Reference section updated to add new HCPCS code E0736, effective 04/01/2024.

04/16/2024: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code M54.5.

10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes M51.360, M51.361, M51.362, M51.369, M51.370, M51.371, M51.372, M51.379, and M62.85. Added new HCPCS codes A4545 and E0737.

03/27/2025: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted HCPCS codes K1016, K1017, K1018, K1019, and K1023.

SOURCE(S)

1. Blue Cross Blue Shield Association policy # 1.01.09

2. Blue Cross Blue Shield Association policy # 1.04.03

3. Blue Cross Blue Shield of Mississippi Durable Medical Equipment Manual

4. Hayes Medical Technology Directory

5. TEC Assessment 1996: Tab 21

6. Technology Evaluation and Coverage 1988: p. 316

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Investigational Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.