This version of the policy will become effective 05/07/2018.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
In 2009, guidelines from the American Academy of Neurology (AAN) published in an online version of Neurology in 2009, stated that transcutaneous electric nerve stimulation (TENS) is not effective for the treatment of chronic low back pain. This recommendation was a level A+, due to lack of proven efficacy.
OTHER ELECTRICAL STIMULATORS
A TENS must be distinguished from a neuromuscular stimulator, which is used to directly stimulate muscles and/or motor nerves, and from percutaneous electrical nerve stimulation (PENS), a minimally invasive stimulator, in which needle-like electrodes are temporarily inserted (to a depth of 1 to 4 centimeters) into the deep tissues (muscles, ligaments, tendons) around or immediately adjacent to the nerve serving the painful area in order to electrically stimulate the peripheral nerve fibers.
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
G89.21 Chronic pain due to trauma
G89.29 Other chronic pain
G89.3 Neoplasm related pain (acute) (chronic)
G89.4 Chronic pain syndrome
Please refer to Attachment A for a list of ICD-codes considered Experimental/Investigational for the use of TENS.
Policy: 07.00.20f:Routine Costs Associated with Qualifying Clinical Trials
Policy: 07.07.07f:Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds