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Coverage criteria policies

Transcutaneous electrical nerve stimulator (TENS) unit

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for Transcutaneous Electrical Nerve Stimulator (TENS) units.

Coverage

TENS units are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

TENS units will be rented for a maximum of six months for these conditions:

  1. Acute post-operative pain
  2. Acute non-malignant pain
  3. Chronic pain conditions (except for chronic low back pain)
  4. Acute exacerbation of chronic conditions (including chronic low back pain).

Electrodes for the TENS unit (code A4595) are covered during the rental period.

Indications / items that are not covered

  1. Purchase of a TENS unit is not covered because scientific evidence does not support its effectiveness for more than 6 months.
  2. TENS is not covered for chronic low back pain because studies show TENS is ineffective for this condition.
  3. TENS is not covered for the following conditions where its use is contraindicated:
    1. Patients with a cardiac pacemaker;
    2. Pregnancy;
    3. Inability to use the device;
    4. Chronic pain that is wide-spread and poorly localized including visceral pain and psychogenic pain.
  4. A conductive garment (E0731) is not covered as it is considered a comfort and convenience item and is not the standard acceptable model of electrodes.
  5. Electrodes for the TENS unit beyond the 6 month rental period.
  6. A transcutaneous supraorbital nerve stimulator to treat or prevent migraines (e.g., Cefaly device or similar product) is not covered because there is insufficient scientific evidence to support its effectiveness.
  7. TENS is not covered for fibromyalgia because there is insufficient scientific evidence to support its effectiveness for this indication.

Definitions

Transcutaneous electrical nerve stimulator (TENS) unit - a device which decreases the patient’s perception of pain. Electrodes are placed on the surface of the skin and small amounts of electric current are delivered through these electrodes. Patients’ pain perception is decreased because pain nerve impulses are decreased and/or endorphins are released.

Transcutaneous supraorbital nerve stimulator to treat or prevent migraines (e.g., Cefaly device or similar product) - Cefaly is a plastic, battery-powered transcutaneous electrical nerve stimulator worn like a headband. It delivers neurostimulation with a 30 mm by 94 mm reusable self-adhesive electrode that is placed on the forehead to cover the supratrochlear and supraorbital nerves (branches of the trigeminal nerve).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

E0720

Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation

E0730

Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation

E0731

Form-fitting conductive garment for delivery of TENS or NMES

A4595

Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)

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

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Dubinsky, R.M., & Miyasaki, J. (2010). Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology (74), 173-76. doi 10.1212/WNL.0b013e3181c918fc
  2. ECRI Institute. (2016). Cefaly Supraorbital Transcutaneous Neurostimulator (Cefaly-Technology) for Preventing and Treating Migraine Headache. Plymouth Meeting, PA: ECRI Institute.
  3. NICE (2016). Transcutaneous electrical stimulation of the supraorbital nerve for treating and preventing migraine. Retrieved from https://www.nice.org.uk/guidance/ipg559
  4. Savigny, P., Kuntze, S., Watson, P., Underwood, M., Ritchie, G., Cotterell, M., … Walsh D. (2009). Low back pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.

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Policy activity

  • 01/01/1994 - Date of origin
  • 05/01/2017 - Effective date
Review date
  • 12/2016
Revision date
  • 01/10/2017

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