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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that 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. 
 
Acute Post-operative Pain 
 
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. 
 
Chronic Pain Other than Low Back Pain 
 
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following 
criteria must be met: 
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): 
headache 
visceral abdominal pain 
pelvic pain 
temporomandibular joint (TMJ) pain 
The pain must have been present for at least three months. 
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.  
 
General Requirements for chronic pain (II) 
 
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. You can find this information in 
Medicare's 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.