Transcutaneous Electrical Nerve Stimulation (TENS) and Transcutaneous Afferent Patterned Stimulation (TAPS)
Does not apply to BlueCare or MedAdvantage members.
DESCRIPTION
Transcutaneous electrical nerve stimulation (TENS) describes the application of electrical stimulation to the surface of the skin at the site of pain. TENS has been investigated to treat chronic intractable pain, postsurgical pain, and pain associated with active or post-trauma injury unresponsive to other standard pain therapies. It has been proposed that TENS may provide pain relief through the release of endorphins in addition to potential blockade of local pain pathways. TENS may be applied in a variety of settings (home, physician’s office, or outpatient clinic).
Transcutaneous afferent patterned stimulation (TAPS) is a novel transcutaneous stimulation application. One example of this technology is the Cala Trio™, which is a wrist-worn stimulator device that applies TAPS to the median and radial nerves of the wrist and has been proposed as an aid in the temporary relief of hand tremors in adults.
POLICY
Transcutaneous electrical nerve stimulation (TENS) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Transcutaneous electrical nerve stimulation (TENS), for the treatment of other conditions/diseases, including, but not limited to, the following is considered investigational:
Temporomandibular Joint Dysfunction (TMJ)
Unstable angina pectoris
Prevention of migraine
Treatment of dementia
Pain during labor and delivery
Management of essential tremor
Attention deficit hyperactivity disorder (ADHD)
Any device utilized for transcutaneous electrical nerve stimulation (TENS) must have FDA approval specific to the indication, otherwise it will be considered investigational.
The use of transcutaneous afferent patterned stimulation (TAPS) is considered investigational.
MEDICAL APPROPRIATENESS
Transcutaneous electrical nerve stimulation (TENS) is considered medically appropriate if ALL of the following criteria are met:
For the management of ANY ONE of the following conditions:
Chronic intractable pain (e.g., musculoskeletal, neuropathic, cancer pain)
Acute postoperative pain
Documentation of ANY ONE of the following:
Initial request as a one-month trial period to permit the physician to study the effects and benefits
Efficacy and compliance have been demonstrated after an initial therapeutic trial
Treatment is administered using ANY ONE of the following applications:
Conventional TENS
Form-fitting conductive TENS garment if ANY ONE of the following are met:
Size of area is not feasible for conventional TENS
Frequency of stimulation required is not feasible for conventional TENS
Sites to be stimulated are inaccessible using conventional TENS
Documented medical condition (e.g., skin problem) precludes the application of conventional TENS
Individual has ANY ONE of the following:
Uncontrolled pain due to diminished effectiveness of medications
Uncontrolled pain due to medication side effects
History of substance abuse
Significant postoperative pain limits the ability to perform exercise programs/physical therapy treatment
Pain unresponsive to conservative measures (e.g., repositioning, heat/ice, etc.)
Absence of ALL of the following:
Inability to understand how to use the TENS unit for pain control
Pregnancy
Implanted device such as pacemaker or defibrillator
Seizure disorder
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
Does not apply to BlueCare or MedAdvantage members.
ADDITIONAL INFORMATION
Overall, evidence for the use of transcutaneous electrical nerve stimulation (TENS) from high-quality trials remains inconclusive for most indications. The available studies are inconsistent on whether TENS improves outcomes, and the overall strength of the evidence is weak for all indications. The best evidence exists for treatment of chronic, intractable pain, and there is strong clinical support for this indication.
SOURCES
American Academy of Neurology. (2010, January; reaffirmed January 2018). Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review). Retrieved April 26, 2019 from https://www.aan.com/Guidelines/home/GuidelineDetail/382.
American Academy of Pediatrics. (2019, October). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Retrieved September 22, 2022 from https://www.aap.org.
Barath, A.S., Rusheen, A.E., Min, H-K., Lee, J., Ross, E., Shin, S., et al. (2020). Brain metabolic changes with longitudinal transcutaneous afferent patterned stimulation in essential tremor subjects. Tremor and Other Hyperkinetic Movements, 10 (1): 52 1-10. (Level 5 evidence)
BlueCross BlueShield Association. Evidence Positioning System. (12:2022). Transcutaneous electrical nerve stimulation (1.01.09). Retrieved October 30, 2023 from www.bcbsaoca.com/eps/. (109 articles and/or guidelines reviewed)
Brillman, S., Colletta, K., Borucki, S., Lin, P.T., Waln, O., Petrossian, M. (2022). Real-world evidence of transcutaneous afferent patterned stimulation for essential tremor. Tremor and Other Hyperkinetic Movements, 12 (27), doi: 10.5334/tohm.715. (Level 4 evidence)
Brillman, S., Khemani, P., Isaacson, S.H., Pahwa, R., Deshpande, R., Zraick, V., et al. (2023). Non-invasive transcutaneous afferent patterned stimulation therapy offers action tremor relief in Parkinson’s disease. Tremor and Other Hyperkinetic Movements, 13 (1):25 1-11.(Level 5 evidence)
Centers for Medicare & Medicaid Services. (2012). CMS.gov. NCD for Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP) (160.27).) Retrieved May 23, 2017 from https://www.cms.gov.
Centers for Medicare & Medicaid Services. (2013). CMS.gov. NCD for Transcutaneous electrical nerve stimulation (TENS) for acute post-operative pain (10.2). Retrieved May 24, 2018 from https://www.cms.gov.
Chen, L., Zhou, Z., Li, Y., Ning, G., Li, Y., Wang, X., & Feng, S. (2016). Transcutaneous electrical nerve stimulation in patients with knee osteoarthritis: evidence from randomized-controlled trials. Clinical Journal of Pain, 32 (2), 146-154. Abstract retrieved May 24, 2017 from PubMed database.
Dai, D., Kim, H., Fernandes, J., & Coetzer, H. (2023). Comparative effectiveness of transcutaneous afferent patterned stimulation therapy for essential tremor: A randomized pragmatic clinical trial. Tremor and Other Hyperkinetic Movements, 13 (1): 38 1-16. (Level 4 evidence)
Gross, T., Schneider, M., Bachmann, L., Blok, B., Groen, J., Hoen, L., et al. (2016). Transcutaneous electrical nerve stimulation for treating neurogenic lower urinary tract dysfunction: a systematic review.European Urology, 69 (6), 1102-1111. (Level 2 evidence)
Institute for Clinical and Economic Review. (2014). Controversies in migraine management. Retrieved December 13, 2021 from https://icer.org/assessment/migraine-acute-chronic-therapies-2014/.
Isaacson, S. H., Peckham, E., Tse, W., Waln, O., Way, C., Petrossian, M. T., et al. (2020). Prospective home-use study on non-invasive neuromodulation therapy for essential tremor. Tremor and Other Hyperkinetic Movements (New York, N.Y.), 10 (29). Doi: 10.5334/tohm.59. (Level 4 evidence)
Johnson, M.I., Paley, C.A., Jones, G., Mulvey, M.R., & Wittkopf, P.G. (2022). Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open, 12 (2), eo51073. (Level 1 evidence)
Lu, C., Khosla, D., Kent, A., Stewart, H.M., & Rosenbluth, K.H. (2023). Transcutaneous afferent patterned stimulation for essential tremor: real-world evidence with long term follow-up. Tremor and Other Hyperkinetic Movements, 13 (1):25 1-11.(Level 5 evidence)
McGough, J. J., Sturm, A., Cowen, J., Tung, K., Salgari, G. C., Leuchter, A. F., et al. (2019). Double-blind, sham-controlled, pilot study of trigeminal nerve stimulation for attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 58 (4), 403–411.e3, doi: 10.1016/j.jaac.2018.11.013. (Level 2 evidence)
National Comprehensive Cancer Network. (2023, July). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Adult cancer pain, version 2.2023. Retrieved October 31, 2023 from the National Comprehensive Cancer Network.
National Institute for Health and Care Excellence. (2014, last updated 2023). Intrapartum care Retrieved October 31, 2023 from www.nice.org.uk/guidance/cg190.
National Institute for Health and Care Excellence. (2016). Stable angina: management. Retrieved January 15, 2021 from www.nice.org.uk/guidance/cg126.
National Institute for Health and Care Excellence. (2016; last update search 2022). Transcutaneous electrical stimulation of the supraorbital nerve for treating and preventing migraine. Retrieved October 31, 2023 from www.nice.org.uk/guidance/cg190.
National Institute for Health and Care Excellence. (2020). Low back pain and sciatica in over 16s: assessment and management. Retrieved January 15, 2021 from www.nice.org.uk/guidance/ng59.
National Institute for Health and Care Excellence. (2021). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of primary chronic pain. Retrieved December 13, 2021 from www.nice.org.uk/guidance/ng193.
National Institute for Health and Care Excellence. (2022). Osteoarthritis in over 16s: care and management. Retrieved October 31, 2023 from www.nice.org.uk/guidance/cg177.
National Institute for Health and Care Excellence. (2023). Transcutaneous electrical stimulation of the trigeminal nerve for ADHD. Retrieved October 31, 2023 from www.nice.org.uk/guidance/cg190.
Resende, L., Merriwether, E., Rampazo, É. P., Dailey, D., Embree, J., Deberg, J., et al. (2018). Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain. European Journal of Pain, 22 (4), 663–678. Abstract retrieved December 13, 2021 from PubMed database.
Salazar, A., Stein, C., Marchese, R., Plentez, R., & Pagnussat, A. (2017). Electric stimulation for pain relief in patients with fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. Pain Physician, 20, 15-25. (Level 1 evidence)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, September; last update search September 2022). Transcutaneous electrical nerve stimulation for chronic low back pain. Retrieved October 4, 2022 from www.Hayesinc.com/subscribers. (68 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2019, January; last update search September 2022). Transcutaneous electrical nerve stimulation for knee osteoarthritis. Retrieved September 15, 2022 from www.Hayesinc.com/subscribers. (64 articles and/or guidelines reviewed)
Wu, L. C., Weng, P. W., Chen, C. H., Huang, Y. Y., Tsuang, Y. H., & Chiang, C. J. (2018). Literature review and meta-analysis of transcutaneous electrical nerve stimulation in treating chronic back pain. Regional Anesthesia and Pain Medicine, 43 (4), 425-433. (Level 2 evidence)
Zhu, Y., Feng, Y., & Peng, L. (2017). Effect of transcutaneous electrical nerve stimulation for pain control after total knee arthroplasty: A systematic review and meta-analysis. Journal of Rehabilitation Medicine, 49 (9), 700-704. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 7/1982
MOST RECENT REVIEW DATE: 12/14/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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