Clinical UM Guideline



Subject: Electrical Nerve Stimulation, Transcutaneous, Percutaneous
Guideline #:  CG-DME-04 Current Effective Date:    09/27/2017
Status: Revised Last Review Date:    08/03/2017

Description

This document addresses transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS). Electrical stimulation is a method used to treat pain through electrodes placed on or just beneath the skin that send small electrical impulses to underlying sensory nerve fibers to modify pain perception. It is theorized that electrical stimulation of the nerve fibers, applied near the segment of the spinal cord, blocks pain signals from reaching the brain. Electrical stimulation is also theorized to reduce inflammation and swelling, and to relax muscle fibers by releasing endorphins in the brain, which act like analgesics. The use of acupuncture with electrical stimulation is not addressed in this document.

Note: Please see the following related document(s) for additional information:

Clinical Indications

Medically Necessary:

  1. Food and Drug Administration (FDA) approved TENS and PENS units are considered medically necessary when prescribed as a treatment for pain for those who have not responded to other modalities, in the following situations:
    1. Pain related to musculoskeletal conditions; or
    2. Pain associated with active or post trauma injury. 
  2. An FDA approved TENS garment, when prescribed, is considered medically necessary when:
    1. There is a large area or many sites to be stimulated such that use of conventional electrodes, adhesive tapes and lead wires is not feasible; or
    2. The areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
    3. There is a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires.

Not Medically Necessary:

Use of TENS and PENS is considered not medically necessary when the above criteria are not met and for all other indications.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS  
A4595 Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
A4630 Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient
E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0731 Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric) [when specified for TENS]
   
ICD-10 Diagnosis  
  All diagnoses
   
Discussion/General Information

TENS uses a battery-operated device that applies electrical stimulation at the site of pain by wired electrodes that are taped to the surface of the skin. TENS can also be delivered through the use of a form-fitting conductive garment (for example, a garment with conductive fibers that are separated from the individual's skin by layers of fabric). This garment is applied when a condition exists that precludes conventional TENS electrode placement. TENS has been used to relieve pain related to musculoskeletal conditions, or pain associated with active or post-trauma injury. 

PENS is similar in concept to TENS, but differs in that needle electrodes are implanted just beneath the skin instead of being taped to the surface of the skin. It is important to distinguish PENS from acupuncture with electrical stimulation. In electrical acupuncture, needle electrodes are also inserted just below the skin, but they are not necessarily inserted at the site of pain, but placed according to acupuncture meridians, a concept of Chinese medicine.

There are many published reports regarding the use of TENS and PENS for various types of conditions such as low back pain (LBP), myofascial and arthritic pain, sympathetically mediated pain, neurogenic pain, visceral pain, diabetic neuropathy and postsurgical pain. While randomized controlled trials (RCTs) have focused on both TENS and PENS, all of the currently available studies have methodological flaws that limit interpretation, including inadequate blinding, lack of reporting of drop outs, lack of reporting of stimulation variables, and lack of proper outcome measures (Johnson, 2015b). However, it is recognized that both TENS and PENS are widely accepted in the physician community as a treatment of a variety of etiologies of pain.

The American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) support the use of TENS in their revised guideline recommending that "TENS should be used as a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g. neck and phantom limb pain)" (ASA/ASRA, 2010).

Current published studies of PENS for neuropathic pain (Raphael, 2011) and TENS for gastric dysmotility with slow transit constipation (Yik, 2011), have shown limited success, but require larger studies to demonstrate clinical efficacy.

Several systematic reviews have been published evaluating the use of TENS in a variety of pain-types, injuries and disorders including, but not limited to, spinal cord injury (Harvey, 2016), rotator cuff injuries (Desmeules, 2016; Page, 2016), soft tissues injuries of the elbow (Dion, 2016), knee osteoarthritis (Chen, 2016; Cherian, 2016), and phantom stump pain (Johnson, 2015a); results revealed weak or inconclusive support for the use TENS for these indications. Support for the use of TENS was found in systematic reviews conducted on its application in the treatment of chronic back pain (Jauregui, 2016), multiple sclerosis (Sawant, 2015) and limb spasticity (Mills, 2016).

References

Peer Reviewed Publications:

  1. Ahmed HE, White PF, Craig WF, et al. Use of percutaneous electrical nerve stimulation (PENS) in the short-term management of headache. Headache. 2000; 40(4):311-315.
  2. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil. 2002; 16(7):749-760.
  3. Cheing GL, Tsui AY, Lo SK, et al. Optimal stimulation duration of TENS in the management of osteoarthritic knee pain. J Rehabil Med. 2003; 35(2):62-68.
  4. Chen LX, Zhou ZR, Li YL, et al. Transcutaneous electrical nerve stimulation in patients with knee osteoarthritis: evidence from randomized-controlled trials. Clin J Pain. 2016; 32(2):146-154.
  5. Cherian JJ, Harrison PE, Benjamin SA, et al. Do the effects of transcutaneous electrical nerve stimulation on knee osteoarthritis pain and function last? J Knee Surg. 2016; 29(6):497-501.
  6. Desmeules F, Boudreault J, Roy J, et al. Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: a systematic review. Physiotherapy. 2016; 102(1):41-49.
  7. de Sousa L, Gomes-Sponholz FA, Nakano AM. Transcutaneous electrical nerve stimulation for the relief of post-partum uterine contraction pain during breast-feeding: a randomized clinical trial. J Obstet Gynaecol Res. 2014; 40(5):1317-1323.
  8. Ghoname EA, Craig WF, White PF et al. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. JAMA. 1999; 281(9):818-823.
  9. Gross T, Schneider MP, Bachmann LM, et al. Transcutaneous electrical nerve stimulation for treating neurogenic lower urinary tract dysfunction: a systematic review. Eur Urol. 2016; 69(6):1102-1111.
  10. Harvey LA, Glinsky JV, Bowden JL. The effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injury: a systematic review. Spinal Cord. 2016; 54(11):914-923.
  11. Jauregui JJ, Cherian JJ, Gwam CU, et al. A meta-analysis of transcutaneous electrical nerve stimulation for chronic low back pain. Surg Technol Int. 2016; 28:296-302.
  12. Jawahar R, Oh U, Yang S, Lapane KL. Alternative approach: a systematic review of non-pharmacological non-spastic and non-trigeminal pain management in multiple sclerosis. Eur J Phys Rehabil Med. 2014; 50(5):567-577.
  13. Kayman-Kose S, Arioz DT, Toktas H, et al. Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section. J Matern Fetal Neonatal Med. 2014; 27(15):1572-1575.
  14. Miller L, Mattison P, Paul L, Wood L. The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis. Mult Scler. 2007; 13(4):527-533
  15. Park J, Seo D, Choi W, Lee S. The effects of exercise with TENS on spasticity, balance, and gait in patients with chronic stroke: a randomized controlled trial. Med Sci Monit. 2014; 20:1890-1896.
  16. Rakel B, Frantz R. Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain. 2003; 4(8):455-464.
  17. Raphael JH, Raheem TA, Southall JL, et al. Randomized double-blind sham-controlled crossover study of short-term effect of percutaneous electrical nerve stimulation in neuropathic pain. Pain Med. 2011; 12(10):1515-1522.
  18. Sawant A, Dadurka K, Overend T, Kremenchutzky M. Systematic review of efficacy of TENS for management of central pain in people with multiple sclerosis. Mult Scler Relat Disord. 2015;4(3):219-227.
  19. Solak O, Turna A, Pekcolaklar A, et al. Transcutaneous electric nerve stimulation for the treatment of postthoracotomy pain: a randomized prospective study. Thorac Cardiovasc Surg. 2007; 55(3):182-185.
  20. Stepanović A, Kolšek M, Kersnik J, Erčulj V. Prevention of post-herpetic neuralgia using transcutaneous electrical nerve stimulation. Wien Klin Wochenschr. 2015; 127(9-10):369-374.
  21. Tokuda M, Tabira K, Masuda T, et al. Effect of modulated-frequency and modulated-intensity transcutaneous electrical nerve stimulation after abdominal surgery: a randomized controlled trial. Clin J Pain. 2014; 30(7):565-570.
  22. Weiner DK, Perera S, Rudy TE, et al. Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial. Pain. 2008; 140(2):344-357.
  23. Weiner DK, Rudy TE, Glick RM, et al. Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain in older adults. J Am Geriatr Soc. 2003; 51(5):599-608.
  24. Yik YI, Clarke MC, Catto-Smith AG, et al. Slow-transit constipation with concurrent upper gastrointestinal dysmotility and its response to transcutaneous electrical stimulation. Pediatr Surg Int. 2011; 27(7):705-711.
  25. Yokoyama M, Sun X, Oku S, et al. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004; 98(6):1552-1556.

Government Agency, Medical Society and Other Authoritative Publications:

  1. Agency for Healthcare Quality and Research (AHRQ). Management of chronic pain. Available at: http://www.guideline.gov/content.aspx?id=47707&search=Transcutaneous+electrical+nerve+stimulation+. Accessed on June 26, 2017.
  2. American Academy of Neurology (AAN). Reaffirmed 2015. Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review). Neurology. 2010; 74(2):173-176.
  3. American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA). Practice guidelines for chronic pain management. Anesthesiology. 2010; 112(4):810-833. 
  4. Brosseau L, Yonge KA, Robinson V, et al. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database Syst Rev. 2003;(2):CD004377.
  5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 26, 2017.
    • Supplies used in the delivery of transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES).NCD #160.13. Effective July 14, 1988.
    • Transcutaneous electrical nerve stimulators (TENS). NCD #280.13. Effective August 7, 1995. Transcutaneous electrical nerve stimulation (TENS) for acute post-operative pain. NCD #10.2. Effective August 7, 1995.
    • Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP). NCD #160.27. Effective June 8, 2012.
  6. Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-491.
  7. Hooten WM, Timming R, Belgrade M, et al. Assessment and management of chronic pain. Institute for Clinical Systems Improvement (ICSI). 2016. Available at: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/pain/ . Accessed on June 26, 2017.
  8. Johnson MI, Mulvey MR, Bagnall AM. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev. 2015a;(8):CD007264.
  9. Johnson MI, Paley CA, Howe TE, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2015b;(6):CD006142.
  10. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;(4):CD003008.
  11. Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013;(8):CD004251.
  12. Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008;(3):CD003222.
  13. Page MJ, Green S, Mrocki MA, et al. Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev. 2016 Jun;(6):CD012225.
  14. Rutjes AWS, Nüesch E, Sterchi R, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis Cochrane Database Syst Rev. 2009;(4):CD002823.
Index

Electrical Nerve Stimulation, Transcutaneous and Percutaneous
PENS (Percutaneous Electrical Nerve Stimulation)
Percutaneous Electrical Nerve Stimulation (PENS)
TENS (Transcutaneous Electrical Nerve Stimulation)
Transcutaneous Electrical Nerve Stimulation (TENS)

History
Status Date Action
Revised 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Added a NMN section. Updated Discussion/General Information and References sections.
Reviewed 08/04/2016 MPTAC review. Updated Discussion/General Information and References. Removed ICD-9 codes from Coding section.
Revised 08/06/2015 MPTAC review. Revised formatting in criteria. Updated Discussion/General Information and References.
Reviewed 08/14/2014 MPTAC review. Updated Discussion/General Information and References.
Reviewed 08/08/2013 MPTAC review. Updated References.
Reviewed 08/03/2012 MPTAC review. Discussion/General Information and References updated.
Reviewed 08/18/2011 MPTAC review. Coding and References updated.
Reviewed 08/19/2010 MPTAC review. Discussion and References updated.
Reviewed 08/27/2009 MPTAC review. References updated.
Reviewed 08/28/2008 MPTAC review. References updated.
Reviewed 08/23/2007 MPTAC review. References updated.
  01/01/2007 Updated coding section with 01/01/2007 CPT/HCPCS changes.
Revised 09/14/2006 MPTAC review. Revision included addressing TENS garment. References updated.
  11/22/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 09/22/2005 MPTAC review. Revisions based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc.   None  
Anthem BCBS   None  
WellPoint Health Networks, Inc. 04/28/2005 5.10.01 Electrical Nerve Stimulation, Transcutaneous, Percutaneous