Aetna Revises DME Policies for TENS

Aetna Health Plan has revised their TENS policy effective 6/25/2013 to state that TENS is considered experimental and investigational for chronic low back pain.

Change in Stance

Aetna now considers transcutaneous electrical nerve stimulators (TENS) medically necessary durable medical equipment (DME) when used as an adjunct or as an alternative to the use of drugs either in the treatment of acute post-operative pain in the first 30 days after surgery, or for certain types of chronic, intractable pain not adequately responsive to other methods of treatment including, as appropriate, physical therapy and pharmacotherapy.

Additionally, TENS is considered experimental and investigational for acute pain (less than 3 months duration) other than post-operative pain. TENS is also considered experimental and investigational for acute and chronic headaches, chronic low back pain, deep abdominal pain, hip fracture pain, neuropathic pain, pelvic pain, temporomandibular joint (TMJ) pain and all other indications because there is inadequate scientific evidence to support its efficacy for these specific types of pain.

When TENS is used for acute post-operative or chronic intractable pain, Aetna considers use of the device medically necessary initially for a trial period of at least 1 month but not to exceed 2 months.

The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. After this 1-month trial period, continued TENS treatment may be considered medically necessary if the treatment significantly alleviates pain and if the attending physician documents that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.

The physician’s records must document a reevaluation of the member at the end of the trial period, must indicate how often the member used the TENS unit, the typical duration of use each time, and the results. The physician ordering the TENS unit must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit.

If the TENS unit produces incomplete relief, further evaluation with percutaneous electrical nerve stimulation (PENS) may be indicated. This coverage policy is consistent with Medicare DMERC guidelines.

List of ICD-9 codes covered if selection criteria are met:

  • 338.18 Other acute postoperative pain
  • 338.21 – 338.29 Chronic pain
  • 338.4 Chronic pain syndrome

ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):

  • 339.00 – 339.89 Other headache syndromes
  • 346.00 – 346.93 Migraine
  • 524.60 – 524.69 Temporomandibular joint disorders
  • 625.0 – 625.9 Pain and other symptoms associated with female genital organs
  • 724.2 Lumbago
  • 784.0 Headache
  • 789.00 – 789.09 Abdominal pain
  • 820.00 – 821.39 Hip fractures [pain]

Other ICD-9 codes related to the CPB:

  • 338.11 Acute pain due to trauma [not covered for acute pain (less than 3 months duration) other than post-operative pain, acute and chronic headaches, deep abdominal pain, hip fracture pain, neuropathic pain, pelvic pain, temporomandibular joint (TMJ) pain]
  • 338.19 Other acute pain [not covered for acute pain (less than 3 months duration) other than post-operative pain, acute and chronic headaches, deep abdominal pain, hip fracture pain, neuropathic pain, pelvic pain, temporomandibular joint (TMJ) pain]
  • 350.1 – 355.9 Mononeuritis [not covered for acute pain (less than 3 months duration) other than post-operative pain or neuropathic pain]
More information can be found at http://www.aetna.com/cpb/medical/data/1_99/0011.html

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Aetna Revises DME Policies for TENS

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