E0731, Form fitting conductive garment for delivery of tens or nmes (with conductive
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- The practitioner ordering the TENS unit and supplies must be the treating practitioner for the disease/condition justifying the need and must monitor the trial period.
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring WOPD, the supplier must have a signed WOPD before delivery.
- For purchases after a trial, the treating practitioner must document that the beneficiary is likely to derive significant therapeutic benefit from continuous long-term use.
- If a 4-lead unit is ordered for 4-lead use, the medical record must document why 2 leads are insufficient to meet the beneficiary's needs.
Key Coverage Criteria
- A TENS unit is covered when ordered by the treating practitioner for treatment of acute post-operative pain, with coverage as a rental beginning the day of surgery.
- A TENS unit is covered for chronic, intractable pain other than chronic low back pain when the presumed etiology is one accepted to respond to TENS therapy.
- Coverage for chronic pain requires pain duration of at least 3 months.
- Coverage for chronic pain requires that other appropriate treatment modalities have been tried and failed prior to ordering TENS.
- A 4-lead TENS may be used when clinically indicated; if ordered for 4-lead use, the medical record must document why 2 leads are insufficient.
- Replacement supplies are covered when reasonable and necessary and used with a covered TENS unit (reimbursement contingent on a covered TENS).
12 Active Policies
ANTHEM-CG-DME-03, CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
ANTHEM-CG-DME-04, CG-DME-04 Transcutaneous Electrical Nerve Stimulation
CIGNA-0160, Electrical Stimulation Therapy and Devices in a Home Setting
L33802, Transcutaneous Electrical Nerve Stimulators (TENS)
L34821, Transcutaneous Electrical Joint Stimulation Devices (TEJSD)
Related Codes
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