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Coverage criteria policies

Transcutaneous electrical nerve stimulator (TENS) unit - Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own 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 TENS units.

Coverage

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

Indications that are covered

  1. Rental of a TENS device is covered for eligible recipients with acute (non-malignant) post-operative or post-traumatic pain.
    1. TENS units will be approved for rental for a period of no more than 60 days following surgery or injury. If the device is required for more than 60 days, the recipient must meet the criteria for chronic pain.
  2. Rental or purchase of a TENS device is covered for eligible recipients with chronic pain other than low back pain.
    1. A TENS device may be medically necessary for chronic pain conditions other than low back pain that are refractory to other recipient-appropriate methods of treatment.
    2. A TENS device will be covered for purchase, or rental until the purchase price is met. After the purchase price is met, the TENS device is the recipient’s property.
  3. A form-fitting conductive garment may be medically necessary for use with a TENS device for some recipients. The purchase of form-fitting conductive garments for use with medically necessary TENS devices is covered when one or more of the following criteria are met:
    1. The area receiving stimulation is inaccessible to the recipient or caregivers with the use of conventional electrodes, tapes, and lead wires
    2. The area receiving stimulation is so large or the areas so numerous conventional electrodes, tapes and lead wires are not practical
    3. The recipient has a skin condition or other medical condition that prevents the application of conventional electrodes, tapes and lead wires
  4. Only TENS devices and conductive garments approved by the Food and Drug Administration (FDA) are covered.
Supplies

One set of 2-lead TENS supplies is covered each month of use for recipients using a 2-lead (E0720) TENS device.

Two sets of 2-lead TENS supplies are covered each month of use for recipients using a 4-lead (E0730) TENS device.

TENS supplies necessary for use of the TENS device for one month include, but are not limited to:

  • Adhesive
  • Adhesive remover
  • Batteries
  • Conductive paste or gel
  • Electrodes

Replacement lead wires are covered no more than twice per year.

Indications that are not covered

  1. TENS is not medically necessary for the treatment of chronic low back pain, defined as low back pain from any cause lasting six weeks or more.
  2. Supplies other than listed above for use with the TENS device are not covered.

Definitions

Transcutaneous electrical nerve stimulator (TENS) is a device that uses electrical current delivered through electrodes placed on the skin to decrease a recipient’s perception of pain by inhibiting the transmission of pain nerve impulses toward the brain and stimulating the release of endorphins.

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

The services associated with these codes do not require prior authorization:

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

A4557

Lead wires (e.g., apnea monitor), per pair

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.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Transcutaneous Electrical Nerve Stimulator (TENS). Revised 09-14-2016.

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Policy activity

  • 01/01/1994 - Date of origin
  • 12/01/2017 - Effective date
Review date
  • 12/2017
Revision date
  • 01/04/2017

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