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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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 The rules say that a transcutaneous electrical nerve stimulator (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. 
I. 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. 
II. 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.  
You can find these rules in 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.