Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the practitioner ordering the Transcutaneous Electrical Nerve Stimulators (TENS) unit and 
related supplies must be the treating practitioner for the disease or condition justifying the need for the TENS 
unit. 
 
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 or II, are met. 
 
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. 
 
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following 
criteria must be met: 
1. 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): 
     a. headache 
     b. visceral abdominal pain 
     c. pelvic pain 
     d. temporomandibular joint (TMJ) pain 
2. The pain must have been present for at least three months. 
3. Other appropriate treatment modalities must have been tried and failed. 
 
TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and necessary. 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.  
 
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 treating practitioner to determine the 
effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the treating practitioner 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 beneficiarys needs. 
 
Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used 
with a covered TENS. Usual maximum utilization is: 
 
2 TENS leads - a maximum of one unit of A4595 per month. 
4 TENS leads - a maximum of two units of A4595 per month. 
If the use of the TENS unit is less than daily, the frequency of billing for the TENS supply code should be 
reduced proportionally. 
 
Reimbursement for supplies is contingent upon use with a covered TENS unit. Claims for TENS supplies 
provided when there is no covered TENS unit will be denied as not reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) Transcutaneous Electrical Nerve 
Stimulators (TENS) L33802. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.