Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME).
The insurer denied TENS device. 
The denial is upheld.

This is a male patient. Diagnoses listed included chronic pain and muscle spasm. Records show the patient has a long history of multiple medical conditions including sleep apnea with temporomandibular joint dysfunction (TMJ disorder). Records provided indicated the patient was treating with his provider for temporomandibular joint (TMJ) disorder and it was noted that the provider was treating the patient with use of transcutaneous electrical nerve stimulation (TENS) to treat the patient's TMJ. It was noted that goals were to relieve symptoms associated with muscle spasm, relax the muscles, and establish a physiological occlusion, increased blood circulation and maintain increase in the mandibular range of motion. The patient was noted to have sleep apnea and chief complaints primarily included sinus congestion, pain with chewing, pain in or around the ears, ringing in the ears, headache, muscle soreness, migraines, limited ability to open the mouth, jaw locking, clicking and pain, frequent heavy snoring, fatigue, facial pain, and dizziness. It was noted the provider was treating with an occlusal orthotic device, orthotic device evaluation and adjustment and electrical stimulation using transcutaneous electric neurostimulation (TENS).

The patient was prescribed a Myotronics Model J-5 Dental TENS unit which was denied by his health plan as not medically necessary. The provider is appealing, stating that the patient's pain was not well-managed with use of alternative treatments such as physical therapy and medications. The provider reported that this device is often used and significantly alleviates pain, muscle spasm and establishes physiologic occlusion, increases blood flow and derived significant therapeutic benefits.
At issue is whether the TENS device is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment TENS device is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
There is no evidence that the proposed health service or treatment TENS (transcutaneous electrical nerve stimulation) device would be likely to be more beneficial than any standard treatment for the patient. The patient is noted to have a history of chronic pain, muscle spasm, sleep apnea, headaches, and TMJ disorder for which the provider was treating him with use of a TENS unit and the provider prescribed a Myotronics Model J-5 Dental TENS unit. There is no high-quality evidence to support use of a TENS unit for the treatment of TMJ or sleep apnea. TENS is considered experimental and investigational for conditions including but not limited to acute and chronic headache, migraine, neuropathic pain, and temporomandibular joint pain according to the Plan's policy. There is no high-quality evidence found in the peer-reviewed medical literature supporting a TENS device as effective for the treatment of sleep apnea or TMJ.

Therefore, the proposed health treatment TENS device is not likely to be more beneficial than any standard treatments.