TENS Unit denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a transcutaneous electrical nerve stimulation (TENS) device. In this case, the patient has been diagnosed with systemic lupus erythematosus and is experiencing chronic pain in his neck, lower back, and legs. The record establishes that the patient has utilized physical, chiropractic, and pharmacological therapy without complete remission of symptoms. Overall, TENS is an appropriate evidence-based treatment option in addition to other conservative therapies in this clinical setting. As such, the requested TENS device is necessary to prevent significant disability and alleviate severe pain through the treatment of a disease. In addition, the TENS device is necessary to attain, maintain, or regain functional capacity.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a transcutaneous electrical nerve stimulation (TENS) unit. The American Physical Therapy Association defines TENS as a noninvasive and safe application of electrical stimulation to the skin for pain control. One group of authors performed a systematic review of several recent randomized controlled trials regarding interventional treatments for postherpetic neuralgia (PHN). Several trials found that the use of TENS resulted in significant reduction in pain scores in the short- and long-term. This patient presents with a diagnosis of PHN. She has tried and failed conservative treatment. The medical literature supports the use of TENS for patients with PHN.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a transcutaneous electrical nerve stimulation (TENS) device and electrodes for treatment of the enrollee’s low back pain with radiation to right anterior thigh. Findings: The physician reviewer found that while TENS may reflect the longstanding accepted standard of care within many medical communities, the results of clinical trials are inconclusive regarding improved health outcomes. Overall, the published studies do not provide information on the stimulation parameters which are most likely to provide optimum pain relief, nor do they answer questions about long-term effectiveness. Several published evidence based assessments of TENS have found that evidence is lacking concerning effectiveness.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacral nerve stimulation for treatment of the enrollee’s anal pain and sphincterotomy. Findings: Two physician reviewers found that within the field of colorectal surgery, the primary indication for sacral nerve stimulation is fecal incontinence. There is a lack of significant data supporting the use of sacral nerve stimulation for levator syndrome, anal pain or chronic pelvic pain. A systematic review on nerve stimulation for chronic pelvic pain and bladder pain syndrome concluded that there were no reported data for sacral nerve stimulation. Additionally, there is a paucity of literature reporting variable success of posterior tibial nerve stimulation in improving pain, urinary symptoms and quality of life for both chronic pelvic pain and bladder pain syndrome.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving TENS Unit, then check the rights and deadlines that apply to your plan.