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 diagnosed with chronic pain and muscle spasms. Records indicate that the patient was prescribed a Myotronics Model J-5 Dental transcutaneous electrical nerve stimulation (TENS) unit which was denied is not medically necessary. The provider indicates that the patient's chronic pain was not manageable with physical therapy or pharmacotherapy. The TENS unit significantly alleviates pain, muscle spasm and establishes physiologic occlusion, increases blood flow and derived significant therapeutic benefits.
There is a letter stating that the patient was seen and treated as an out of network service provider focusing on treatment of neuromuscular orthopedics and alternative adjunctive therapies for obstructive sleep apnea, temporomandibular joint (TMJ) disorder and chronic pain. It was stated that TENS was performed during the initial 6-hour exam, subsequent appointments and treatments at this office and was prescribed to treat the patient's TMJ dysfunction and pain, 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 chief complaints including back pain, sinus congestion, pain with chewing, pain in or around the ears, ringing in the ears, muscle soreness, morning head pain, migraine, headaches, neck pain, limited mouth opening, jaw locking, jaw clicking, jaw pain, frequent heavy snoring, fatigue, facial pain, dizziness, shoulder pain and ringing in the ears. The plan was for ongoing treatment with occlusal orthotic device, orthotic device evaluation and adjustment and electrical stimulation using transcutaneous electric neurostimulation (TENS).
At issue is whether the proposed health service or treatment TENS device is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.
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 or treatments for the insured's life threatening or disabling condition or disease.

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 the 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. According to the Plan's policy, TENS is experimental and investigational for conditions including but not limited to acute and chronic headache, migraine, neuropathic pain, temporomandibular joint pain. There is no high-quality evidence found in the peer-reviewed medical literature suggesting that TENS is effective for the treatment of sleep apnea or TMJ.

Therefore, the proposed health service or treatment TENS (transcutaneous electrical nerve stimulation) device would not be likely to be more beneficial than any standard treatment or treatments for the patient's condition.