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TENS Unit denials: what the review data shows
Independent reviewers have decided 22 published cases where an insurer denied TENS Unit — and they overturned the insurer 22.7% of the time. A denial for TENS Unit is a starting position, not a final answer.
Published decisions
22
2001–2026
Overturned
22.7%
5 denials reversed
Conditions behind tens unit denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Back Pain | 4 | 0% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 14 | 28.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 12.5% |
Typical time to a decision
20 days
Most land between 11 and 22 days
Handled as urgent
18.2%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
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
Worth reading too — these show what an appeal has to overcome.
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for TENS Unitwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.