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December 2016

Reminder: Coverage criteria for TENS unit

As a reminder, since March 1, 2013, Blue Cross Blue Shield of Michigan has aligned with the Centers for Medicare & Medicaid Services’ medical necessity criteria for the transcutaneous electrical nerves stimulation unit. A TENS unit is covered for the treatment of patients who meet the coverage criteria with chronic intractable pain or acute post-operative pain.

For acute post-operative pain:

  • The medical necessity is usually limited to 30 days from the day of surgery.
  • Payment for more than one month is determined by individual consideration based upon supportive documentation provided by the attending doctor.
  • Payment will be made only as a rental.
  • A refund request will be made for a TENS unit on post audit as not reasonable and necessary for acute pain (less than three months duration) other than post-operative pain.

For chronic pain:

  • The medical record must document the location of the pain, the duration of time the patient has had the pain and the presumed etiology of the pain.
  • The pain must have been present for at least three months.
  • Other appropriate treatment modalities must have been tried and failed.
  • The medical record must document what treatment modalities have been used.
  • The presumed etiology of the pain must be a type that's accepted as responding to TENS therapy.

When used for the treatment of chronic, intractable pain:

  • The TENS unit must be used by the patient on a trial basis for a minimum of one month (30 days), but not to exceed two months.
  • The trial period will be paid as a rental.
  • The trial period must be monitored by the doctor to determine the effectiveness of the TENS unit in modulating the pain.

For coverage of a purchase:

  • The physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.
  • The doctor’s records must document a re-evaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time and the results.

Examples of conditions for which a TENS unit aren’t considered medically necessary (not all-inclusive):

  • Headache
  • Visceral abdominal pain
  • Pelvic pain
  • Temporomandibular joint pain

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
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