LCD - Tens Unit
- Written Order Prior to Delivery
- TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain.
- DME Order Form
- Dr. must be PECOS registered for all Medicare orders.
- Patient's Name
- Detailed description of item(s) being ordered
- Qty to be dispensed
- Prescribed settings
- Prescribed frequency of use
- Length of Medical Need
- Treating Physician’s NPI
- Treating physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
- Treating physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
- Start date of the order – if different than signature date.
A TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain when one of the following coverage criteria, I-III, are met.
I. Acute Post-operative Pain
- TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month's rental) from the day of surgery. Payment will be made only as a rental.
- A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months duration other than for post-operative pain.
II. Chronic Pain Other than Low Back Pain
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following criteria must be met:
- The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive):
- visceral abdominal pain
- pelvic pain
- temporomandibular joint (TMJ) pain
The pain must have been present for at least three months. Other appropriate treatment modalities must have been tried and failed.
III. Chronic Low Back Pain (CLBP)
TENS therapy for CLBP is only covered when all of the following criteria are met:
- The beneficiary has one of the following ICD-9 diagnoses listed in the diagnosis section below.
- The beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD §160.27 (CMS Internet Only Manual 100-3, Chapter 1). Refer to the LCD APPENDICES section for additional information about approved clinical studies.
General Requirements for chronic pain (II) and CLBP (III)
- When used for the treatment of chronic, intractable pain described in section II, the TENS unit must be used by the beneficiary 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 physician to determine the effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the physician must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.
- A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the characteristics of the beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the beneficiary’s needs.
- TENS used for CLBP as described in section III does not require a trial rental period or an assessment of effectiveness by the treating physician. Upon the beneficiary’s enrollment into an approved study, the TENS is eligible for purchase.
Chronic Low Back Pain - Diagnosis Section:
|353.4||LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED|
|720.2||SACROILIITIS NOT ELSEWHERE CLASSIFIED|
|721.3||LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY|
|721.42||SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION|
|722.10||DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY|
|722.52||DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC|
|722.73||INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION|
|722.83||POSTLAMINECTOMY SYNDROME OF LUMBAR REGION|
|722.93||OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION|
|724.02||SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION|
|724.03||SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION|
|724.4||THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED|
|739.3||NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED|
|756.11||CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION|
|805.4||CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY|
|806.4||CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY|
|846.0||LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN|
|846.1||SACROILIAC (LIGAMENT) SPRAIN|
|953.2||INJURY TO LUMBAR NERVE ROOT|