Clinical Policy Guideline

Transcription

1 Clinical Policy Guideline Policy Title: Transcutaneous Electrical Nerve Stimulation (TENS) Effective Date: 09/2012 Date Reviewed: 02/20/2013, 03/09/2016 I. DEFINITION Transcutaneous electrical nerve stimulations (TENS) utilize electrical current delivered through electrodes placed on the surface of the skin to decrease pain. In theory, it is proposed that TENS stimulates sensory nerves to block pain signals, and also stimulates endorphin production. TENS has been widely used for treatment of various types of pain. II. POLICY/CRITERIA Documentation supporting medical necessity must be demonstrated in the member s medical record. Documentation must be legible and contain relevant history and physical findings to meet the criteria listed below. A TENS is covered for the treatment of chronic, intractable pain or acute post-operative pain as follows: I. Acute Post-operative Pain a. TENS is covered for acute post-operative pain. Coverage is limited to 30 days from the day of surgery. Payment will be made only as a rental. b. A TENS unit will be denied as not medically 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 are met: Page 1 of 10

2 a. 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 medically 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 b. TENS therapy for chronic pain that does not meet these criteria will be denied as not medically necessary. III. Chronic Low Back Pain (CLBP) Evidence from peer-reviewed published studies is conflicting in regards to the efficacy of this treatment for patients with chronic low back pain. The use of TENS for the treatment of chronic low back pain is not a covered benefit, unless otherwise specified in members benefit plan. MEDICAID TENS for the treatment of chronic low back pain is a covered benefit for Medicaid members according to the MDCH Medicaid Coverage Criteria. A Prior Authorization is required upon initial request and if approved, the device will be covered for 90 days. For continued use, a PA will be required, and every 30 days thereafter. Documentation must be within the past 30 days and include the Medication regimen, before and after use, and the functional level before and after use. PROCESSING REQUIREMENTS FOR MEDICARE Medicare allows coverage for chronic low back pain within the context of a clinical trial. EXCEPTION: Medicare Advantage Plans are required to pay for a member who is in an approved clinical trial for low back pain. (All other clinical trials are covered by Original Medicare.) Effective June 8, 2012 per Medicare guidelines coverage of TENS for chronic low back pain must meet the following: Pain exceeds more than 3 months, Is not the manifestation of a clearly defined and generally recognizable primary disease entity, The patient must be enrolled in an approved clinical study under coverage of evidence of development. Page 2 of 10

3 Medicare states that contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying the patient has chronic low back pain (CLBP) defined as an episode of low back pain that has persisted for three months or longer; and that the CLBP is not a manifestation of a clearly defined and generally recognizable primary disease entity as described in the TENS coverage policy for CLBP. Claims should include; Date of service on or after June 8, 2012 TENS HCPCS code Modifiers RR, KX and Q0 An acceptable ICD-9 code, and/or An acceptable ICD-10 code upon implementation Below is the link to access the Certificate of Medical Necessity required for a Transcutaneous Electrical Nerve Stimulator (TENS), a provider must have this form on file if the individual meets medical criteria as required by Medicare for payment. III. PRIOR AUTHORIZATION REQUIREMENTS A prior authorization is required from a HealthPlus Plan Medical Reviewer. IV. CODING/MODIFIERS/LOCATION OF SERVICE Applicable CPT Codes: E0720 Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation E0730 Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation Applicable Modifiers: RR Rental of durable medical equipment KX Requirements specified in the medical policy have been met Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study (see below for special instructions for this guideline) Covered Location of Service: 12- Home Page 3 of 10

4 ICD-9 Code Covered ICD-10 Diagnosis Codes: ICD-9 Name Lumbosacral root lesions, not elsewhere classified ICD-10 Code ICD-10 Name G54.4 Lumbosacral root disorders, not elsewhere classified Sacroiliitis, not elsewhere classified M46.1 Sacroiliitis, not elsewhere classified Spondylosis with, lumbar Spondylosis with, lumbar Spondylosis with, lumbar Displacement of lumbar intervertebral disc without Displacement of lumbar intervertebral disc without Degeneration of lumbar or lumbosacral intervertebral disc Degeneration of lumbar or lumbosacral intervertebral disc Intervertebral disc disorder with, lumbar Intervertebral disc disorder with, lumbar Postlaminectomy syndrome of lumbar M47.26 Other spondylosis with radiculopathy, lumbar M47.27 Other spondylosis with radiculopathy, lumbosacral M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal M Spondylosis without or radiculopathy, lumbar M Spondylosis without or radiculopathy, lumbosacral M Spondylosis without or radiculopathy, sacral and sacrococcygeal M Other spondylosis, lumbar M Other spondylosis, lumbosacral M Other spondylosis, sacral and sacrococcygeal M47.16 Other spondylosis with, lumbar M47.17 Other spondylosis with, lumbosacral M47.18 Other spondylosis with, sacral and sacrococcygeal M51.26 Other intervertebral disc displacement, lumbar M51.27 Other intervertebral disc displacement, lumbosacral M51.36 Other intervertebral disc degeneration, lumbar M51.37 Other intervertebral disc degeneration, lumbosacral M51.06 Intervertebral disc disorders with, lumbar M51.07 Intervertebral disc disorders with, lumbosacral M96.1 Postlaminectomy syndrome, not elsewhere classified Page 4 of 10

5 Other and unspecified disc disorder of lumbar Other and unspecified disc disorder of lumbar Other and unspecified disc disorder of lumbar Other and unspecified disc disorder of lumbar Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar without Spinal stenosis of lumbar with M46.46 Discitis, unspecified, lumbar M46.47 Discitis, unspecified, lumbosacral M51.86 Other intervertebral disc disorders, lumbar M51.87 Other intervertebral disc disorders, lumbosacral M48.06 Spinal stenosis, lumbar M48.07 Spinal stenosis, lumbosacral M99.23 Subluxation stenosis of neural canal of lumbar M99.33 Osseous stenosis of neural canal of lumbar M99.43 Connective tissue stenosis of neural canal of lumbar M99.53 Intervertebral disc stenosis of neural canal of lumbar M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar M48.06 Spinal stenosis, lumbar Lumbago M54.5 Low back pain Sciatica M54.30 Sciatica, unspecified side Sciatica M54.31 Sciatica, right side Sciatica M54.32 Sciatica, left side Sciatica M54.40 Lumbago with sciatica, unspecified side Sciatica M54.41 Lumbago with sciatica, right side Sciatica M54.42 Lumbago with sciatica, left side M51.14 Intervertebral disc disorders with radiculopathy, thoracic M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar M51.16 Intervertebral disc disorders with radiculopathy, lumbar Page 5 of 10

6 M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral M54.14 Radiculopathy, thoracic M54.15 Radiculopathy, thoracolumbar M54.16 Radiculopathy, lumbar M54.17 Radiculopathy, lumbosacral Acquired spondylolisthesis M43.00 Spondylolysis, site unspecified Acquired spondylolisthesis M43.01 Spondylolysis, occipito-atlanto-axial Acquired spondylolisthesis M43.02 Spondylolysis, cervical Acquired spondylolisthesis M43.03 Spondylolysis, cervicothoracic Acquired spondylolisthesis M43.04 Spondylolysis, thoracic Acquired spondylolisthesis M43.05 Spondylolysis, thoracolumbar Acquired spondylolisthesis M43.06 Spondylolysis, lumbar Acquired spondylolisthesis M43.07 Spondylolysis, lumbosacral Acquired spondylolisthesis M43.08 Spondylolysis, sacral and sacrococcygeal Acquired spondylolisthesis M43.09 Spondylolysis, multiple sites in spine Acquired spondylolisthesis M43.10 Spondylolisthesis, site unspecified Acquired spondylolisthesis M43.11 Spondylolisthesis, occipito-atlanto-axial Acquired spondylolisthesis M43.12 Spondylolisthesis, cervical Acquired spondylolisthesis M43.13 Spondylolisthesis, cervicothoracic Acquired spondylolisthesis M43.14 Spondylolisthesis, thoracic Acquired spondylolisthesis M43.15 Spondylolisthesis, thoracolumbar Acquired spondylolisthesis M43.16 Spondylolisthesis, lumbar Acquired spondylolisthesis M43.17 Spondylolisthesis, lumbosacral Page 6 of 10

7 738.4 Acquired spondylolisthesis M43.18 Spondylolisthesis, sacral and sacrococcygeal Acquired spondylolisthesis M43.19 Spondylolisthesis, multiple sites in spine Nonallopathic lesions of lumbar, not elsewhere classified Spondylolysis, congenital, lumbosacral M99.03 Segmental and somatic dysfunction of lumbar Q76.2 Congenital spondylolisthesis Spondylolisthesis, congenital Q76.2 Congenital spondylolisthesis S32.000A S32.001A S32.002A S32.008A S32.009A S32.010A S32.011A S32.012A S32.018A S32.019A S32.020A S32.021A S32.022A S32.028A S32.029A S32.030A S32.031A S32.032A Wedge compression fracture of unspecified lumbar vertebra, for closed Stable burst fracture of unspecified lumbar vertebra, initial Unstable burst fracture of unspecified lumbar vertebra, initial Other fracture of unspecified lumbar vertebra, initial Unspecified fracture of unspecified lumbar vertebra, initial Wedge compression fracture of first lumbar vertebra, initial Stable burst fracture of first lumbar vertebra, initial Unstable burst fracture of first lumbar vertebra, initial Other fracture of first lumbar vertebra, initial Unspecified fracture of first lumbar vertebra, initial Wedge compression fracture of second lumbar vertebra, initial Stable burst fracture of second lumbar vertebra, initial Unstable burst fracture of second lumbar vertebra, initial Other fracture of second lumbar vertebra, initial Unspecified fracture of second lumbar vertebra, initial Wedge compression fracture of third lumbar vertebra, initial Stable burst fracture of third lumbar vertebra, initial Unstable burst fracture of third lumbar vertebra, initial Page 7 of 10

8 S32.038A S32.039A S32.040A S32.041A S32.042A S32.048A S32.049A S32.050A S32.051A S32.052A S32.058A S32.059A S32.009A S32.019A S32.029A S32.039A S32.049A S32.059A S34.101A S34.102A S34.103A S34.104A S34.105A Other fracture of third lumbar vertebra, initial Unspecified fracture of third lumbar vertebra, initial Wedge compression fracture of fourth lumbar vertebra, initial Stable burst fracture of fourth lumbar vertebra, initial Unstable burst fracture of fourth lumbar vertebra, initial Other fracture of fourth lumbar vertebra, initial Unspecified fracture of fourth lumbar vertebra, initial Wedge compression fracture of fifth lumbar vertebra, initial Stable burst fracture of fifth lumbar vertebra, initial Unstable burst fracture of fifth lumbar vertebra, initial Other fracture of fifth lumbar vertebra, initial Unspecified fracture of fifth lumbar vertebra, initial Unspecified fracture of unspecified lumbar vertebra, initial Unspecified fracture of first lumbar vertebra, initial Unspecified fracture of second lumbar vertebra, initial Unspecified fracture of third lumbar vertebra, initial Unspecified fracture of fourth lumbar vertebra, initial Unspecified fracture of fifth lumbar vertebra, initial Unspecified injury to L1 level of lumbar spinal cord, Unspecified injury to L2 level of lumbar spinal cord, Unspecified injury to L3 level of lumbar spinal cord, Unspecified injury to L4 level of lumbar spinal cord, Unspecified injury to L5 level of lumbar spinal cord, Page 8 of 10

9 S34.109A S34.111A S34.112A S34.113A S34.114A S34.115A S34.119A S34.121A S34.122A S34.123A S34.124A S34.125A S34.129A Unspecified injury to unspecified level of lumbar spinal cord, Complete lesion of L1 level of lumbar spinal cord, Complete lesion of L2 level of lumbar spinal cord, Complete lesion of L3 level of lumbar spinal cord, Complete lesion of L4 level of lumbar spinal cord, Complete lesion of L5 level of lumbar spinal cord, Complete lesion of unspecified level of lumbar spinal cord, Incomplete lesion of L1 level of lumbar spinal cord, Incomplete lesion of L2 level of lumbar spinal cord, Incomplete lesion of L3 level of lumbar spinal cord, Incomplete lesion of L4 level of lumbar spinal cord, Incomplete lesion of L5 level of lumbar spinal cord, Incomplete lesion of unspecified level of lumbar spinal cord, Lumbosacral (joint) (ligament) sprain S33.8xxA Sprain of other parts of lumbar spine and pelvis, initial encounter Sacroiliac (ligament) sprain S33.6xxA Sprain of sacroiliac joint, Lumbar sprain S33.5xxA Sprain of ligaments of lumbar spine, Injury to lumbar nerve root S34.21xA Injury of nerve root of lumbar spine, V70.7 Examination of participant in clinical trial Z00.6 Encounter for examination for normal comparison and control in clinical research V. PRODUCT LINE COVERAGE Please reference contract benefit rider, benefit description, Master Plan Document, Evidence of Coverage (EoC) and Certificate of Coverage (CoC) for applicable limits and copayments, including other exceptions and/or exclusions for specific coverage. If there is a conflict between this medical policy and the individual or group insurance policy document, the terms of the individual or group insurance policy will govern, unless specifically Page 9 of 10

10 noted. HMO: This policy applies to insured HMO plans; refer to the CoC or benefit rider for exceptions or exclusions. PPO: This policy applies to PPO plans; refer to the CoC for any exceptions or exclusions. SELF-FUNDED OPTIONS: This policy applies to self-funded option plans; refer to the Master Plan Document for any exceptions or exclusions. MEDICARE ADVANTAGE: This policy applies to insured Medicare Advantage plans; refer to the EoC for any exceptions or exclusions. MEDICAID: This policy applies to Medicaid plans; refer to the subscriber contract for exceptions or exclusions. HEALTHY MICHIGAN PLAN: This policy applies to Healthy Michigan Plan; refer to the subscriber contract for any exceptions or exclusions. MICHILD: This policy applies to insured MICHILD plans; refer to the subscriber contract for any exceptions or exclusions. COUNTY HEALTH PLANS: This policy applies to County Health Plans; refer to the benefit description for any exceptions or exclusions. VI. REFERENCES References are available upon request. AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association. This policy is for informational use only; therefore it is not an authorization of services. HealthPlus of Michigan s clinical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, HealthPlus of Michigan reserves the right to review and update its clinical policies at its discretion. HealthPlus of Michigan s clinical policies are intended to serve as a resource to the plan; however they are not intended to limit the plan s interpretation of benefit language. HealthPlus of Michigan does not provide health care services and cannot guarantee results or outcomes. Treating providers are solely responsible for rendering medical advice and treatment to members. Page 10 of 10