S8130, Interferential current stimulator, 2 channel
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
- No other explicit documentation requirements, prior-authorization criteria, ICD-10 diagnoses, frequency limits, or billing/coding instructions are provided in this document excerpt.
- If 4 TENS leads are ordered for a 4-lead TENS unit, "the medical record must document why 2 leads are insufficient to meet the member's needs."
- Before implanting the ReActiv8 device, "multifudus muscle atrophy and weakness must be shown using magnetic resonance imaging (MRI) or during a physical examination using the prone instability test." (Documentation requirement for candidates for implantation.)
Key Coverage Criteria
- PENS (ICD-10 codes covered if selection criteria are met): M79.2 Neuralgia and neuritis, unspecified [neuropathic pain]
- Transcutaneous Electrical Nerve Stimulators (TENS) medically necessary when used as an adjunct or as an alternative to the use of drugs either in the treatment of acute post-operative pain in the first 30 days after surgery, or for certain types of chronic, intractable pain not adequately responsive to other methods of treatment including, as appropriate, physical therapy and pharmacotherapy.
- When TENS is used for acute post-operative or chronic intractable pain, initial medically necessary use is for a trial period of at least 1 month but not to exceed 2 months, monitored by the physician to determine effectiveness.
- Form-fitting conductive garment medically necessary DME only when it has been approved for marketing by the FDA, has been prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above, and any of the following criteria is met: the member cannot manage without the conductive garment due to large area or number of sites to be stimulated and frequent delivery is required; or the member has a medical need for rehabilitation strengthening following an injury w [...]
- G90.50 - G90.59 Complex regional pain syndrome I (CRPS I) (covered if selection criteria are met for peripherally implanted nerve stimulators)
- S14.101S - S14.159S; S14.2xxS - S14.9xxS; S24.101S - S24.159S; S24.2xxS - S24.9xxS; S34.101S - S34.139S; S34.21xS - S34.9xxS; S44.8x1S - S44.92xS; S54.8x1S - S54.92xS; S64.8x1S - S64.92xS; S74.8x1S - S74.92xS; S84.801S - S84.92xS; S94.8x1S - S94.92xS (spinal cord injury, injury to nerve root(s), spinal plexus(s), and other nerves of trunk, injury to peripheral nerve of shoulder girdle and upper limb, or injury to peripheral nerve of pelvic girdle and lower limb, sequela) — covered if selection c [...]
12 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
AETNA-CPB-0011, Peripheral Electrical Nerve Stimulation for Pain
MED201.041, Interferential Current Stimulation
Related Codes
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