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. 
 
Transcutaneous Electrical Nerve Stimulation (TENS) and/or Neuromuscular Electrical Stimulation (NMES) 
can ordinarily be delivered to patients through the use of conventional electrodes, adhesive tapes and lead 
wires. There may be times, however, where it might be medically necessary for certain patients receiving 
TENS or NMES treatment to use, as an alternative to conventional electrodes, adhesive tapes and lead wires, a 
form-fitting conductive garment (i.e., a garment with conductive fibers which are separated from the patients 
skin by layers of fabric). 
 
Indications and Limitations of Coverage 
A form-fitting conductive garment (and medically necessary related supplies) may be covered under the 
program only when: 
1. It has received permission or approval for marketing by the Food and Drug Administration; 
2. It has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and 
3. One of the medical indications outlined below is met: 
 The patient cannot manage without the conductive garment because there is such a large area or so 
many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not 
feasible to use conventional electrodes, adhesive tapes and lead wires; 
 The patient cannot manage without the conductive garment for the treatment of chronic intractable pain 
because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, 
adhesive tapes and lead wires; 
 The patient has a documented medical condition such as skin problems that preclude the application of 
conventional electrodes, adhesive tapes and lead wires; 
 The patient requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve 
supply to the muscle is intact, or to treat chronic intractable pain; or 
 The patient has a medical need for rehabilitation strengthening (pursuant to a written plan of 
rehabilitation) following an injury where the nerve supply to the muscle is intact. A conductive garment is not covered for use with a TENS device during the trial period specified in 
160.3 unless: 
4. The patient has a documented skin problem prior to the start of the trial period; and 
5. The B/Medicare Administrative Contractors medical consultants are satisfied that use of such an item is 
medically necessary for the patient. 
(See conditions for coverage of the use of TENS in the diagnosis and treatment of chronic intractable pain in 
160.3, 160.13, and 160.27, and the use of NMES in the treatment of disuse atrophy in 150.4.) 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 160.13. 
 
TENS is not reasonable and necessary for the treatment of chronic low back pain (CLBP) under section 1862 
(a)(1)(A) of the Act.  
 
Effective June 8, 2012, the Centers for Medicare & Medicaid Services (CMS) will allow coverage for 
Transcutaneous Electrical Nerve Stimulation (TENS) for CLBP only when all of the following conditions are 
met. 
In order to support additional research on the use of TENS for CLBP, we will cover this item under section 
1862(a)(1)(E) of the Social Security Act (the Act) subject to all of the following conditions: 
1. Coverage under this section expires three years after the publication of this decision on the CMS 
website. 
2. The beneficiary is enrolled in an approved clinical study meeting all of the requirements below. The 
study must address one or more aspects of the following questions in a randomized, controlled design 
using validated and reliable instruments. This can include randomized crossover designs when the 
impact of prior TENS use is appropriately accounted for in the study protocol. 
i. Does the use of TENS provide clinically meaningful reduction in pain in Medicare beneficiaries 
with CLBP? 
ii. Does the use of TENS provide a clinically meaningful improvement of function in Medicare 
beneficiaries with CLBP? 
iii. Does the use of TENS impact the utilization of other medical treatments or services used in the 
medical management of CLBP? 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 160.27. 
 
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.