E0721 — Transcutaneous electrical nerve stimulator for nerves in the auricular region
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews. For FES for lower limb paralysis due to SCI, documentation should demonstrate each of the listed required criteria (exact wording):
- Demonstration of intact lower motor units (L1 and below) (both muscle and peripheral nerves)
- Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently
- Demonstration of brisk muscle contraction
Key Coverage Criteria
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Transcutaneous Electrical Nerve Stimulation (TENS). [...]
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Presence of ANY of the following chronic wound types: Stage 3 or stage 4 pressure injury; arterial ulcer; neuropathic (diabetic) ulcer; venous stasis ulcer.
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Failure to demonstrate measurable signs of improved healing (e.g., signs of epithelialization and reduction in ulcer size) with a 30-day trial of conventional wound management, including optimization of nutritional status, moist dressings and debridement.
- Electrical stimulation (HCPCS Code G0281) is considered medically necessary for the treatment of a chronic wound when ALL of the following criteria are met: Electrical stimulation therapy is performed under the direct supervision of a medical professional with expertise in wound evaluation and management.
- Neuromuscular electrical stimulation (NMES) (HCPCS Code E0745) and related supplies (HCPCS Code A4595) are considered medically necessary when used as one component of a comprehensive rehabilitation program for the treatment of disuse atrophy when the nerve supply to the atrophied muscle is intact.
- Transcutaneous electrical nerve stimulator (TENS) (HCPCS Codes E0720, E0730) and related supplies (HCPCS Code A4595) are considered medically necessary for in-home use as an adjunct to conventional post-operative pain management within 30 days of surgery.
7 Active Policies
CIGNA-0160-FUTURE — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
CIGNA-0160 — Electrical Stimulation Therapy and Devices in a Home Setting - (0160)
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
ANTHEM-DME.00011 — DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
Related Codes
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