E0743, External lower extremity nerve stimulator for restless legs syndrome, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims may require medical records documentation to assess whether the member meets the clinical criteria for coverage; however, documentation does not guarantee coverage.
- Medical Records Documentation Used for Reviews
- Documentation: clinicians may need to submit clinical documentation to support the service request.
- review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
Key Coverage Criteria
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances.
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances.
- Suspected OSA: observed apneas during sleep.
- Home sleep apnea studies are medically necessary for suspected OSA when the patient meets any of the listed criteria.
- Suspected OSA: requires a combination of at least two of the five listed criteria.
- Obesity threshold for suspected OSA: BMI > 30 kg/m2.
9 Active Policies
ANTHEM-DME.00011, DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
SUREST-POL-SUREST-electrical-stimulation-treatment-pain-muscle-rehabilitation, Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
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