Aetna · Clinical coverage policy

Aetna Electrical Stimulation for Pain (TENS/PENS) coverage criteria

Aetna covers TENS as DME for acute post-operative pain (first 30 days) or certain chronic intractable pain not responsive to other treatments, starting with a 1-2 month trial that must be documented as significantly relieving pain before continued use is approved; it also covers PENS for specific back pain and neuropathy situations and peripherally implanted nerve stimulators for intractable neuropathic pain when strict criteria (refractory pain, objective pathology, named nerve, and a successful >=50% percutaneous trial) are all met. A very long list of other indications and devices (e.g., TENS for most chronic/neuropathic pain conditions, interferential stimulation, microcurrent/MENS, Scrambler/Calmare, H-Wave, sympathetic therapy, auricular and peripheral field stimulation) is considered experimental/investigational and not covered. The bulletin is silent on precertification/prior authorization.

Policy CPB 0011 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0011

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0011 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Electrical Stimulation for Pain (TENS/PENS) (CPT E0720), and what gets it denied?

Path
Aetna covers TENS as DME for acute post-operative pain (first 30 days) or certain chronic intractable pain not responsive to other treatments, starting with a 1-2 month trial that must be documented as significantly relieving pain before continued use is approved; it also covers PENS for specific back pain and neuropathy situations and peripherally implanted nerve stimulators for intractable neuropathic pain when strict criteria (refractory pain, objective pathology, named nerve, and a successful >=50% percutaneous trial) are all met. A very long list of other indications and devices (e.g., TENS for most chronic/neuropathic pain conditions, interferential stimulation, microcurrent/MENS, Scrambler/Calmare, H-Wave, sympathetic therapy, auricular and peripheral field stimulation) is considered experimental/investigational and not covered. The bulletin is silent on precertification/prior authorization. Coverage criteria include: TENS (transcutaneous electrical nerve stimulators) is medically necessary DME when used as an adjunct or alternative to drugs EITHER (ONE of): 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; TENS for acute post-operative or chronic intractable pain: device is medically necessary INITIALLY for a trial period of at least 1 month but not to exceed 2 months; Continued TENS after the 1-month trial is medically necessary IF (ALL): the treatment significantly alleviates pain; AND 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; TENS ordering physician must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit; Form-fitting conductive garment is medically necessary DME ONLY when (ALL of): FDA-approved for marketing; AND prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above; AND (ONE of the following): (1) member cannot manage without the conductive garment due to the large area or large number of sites to be stimulated and stimulation must be delivered so frequently that conventional electrodes/adhesive tapes/lead wires are not feasible; OR (2) member has a medical need for rehabilitation strengthening following an injury where the nerve supply to the muscle is intact; OR (3) member has a skin problem or other medical condition that precludes application of conventional electrodes/adhesive tapes/lead wires; OR (4) member requires electrical stimulation beneath a cast to treat disuse atrophy where the nerve supply to the muscle is intact; PENS (percutaneous electrical nerve stimulation) is medically necessary DME (ONE of): (1) up to a 30-day period for treatment of chronic low back pain secondary to degenerative disc disease when PENS is used as part of a multi-modality rehabilitation program that includes exercise; OR (2) treatment of diabetic neuropathy or neuropathic pain in members who failed to adequately respond to conventional treatments including three or more of the following groups of agents: anti-convulsants (e.g., pregabalin), anti-depressants (e.g., amitriptyline, duloxetine), opioids (e.g., morphine sulphate, tramadol), and other pharmacological agents (e.g., capsaicin, isosorbide dinitrate spray); Peripherally implanted nerve stimulators (e.g., Curonix Freedom PNS, Nalu PNS, SPRINT PNS, StimRouter) are medically necessary DME for intractable neuropathic pain when ALL of: (1) member has chronic intractable pain refractory to other methods of treatment (e.g., analgesics and other medications including TCAs, SSRIs, SNRIs and antiseizure medications where appropriate, physical therapy in-person for at least 6 weeks in the past year, local injection, surgery); AND (2) member is not addicted to drugs (per American Society of Addiction Medicine guidelines); AND (3) there is no psychological contraindication to peripheral nerve stimulation (Note: formal psychological evaluation not required); AND (4) there is objective evidence of pathology (e.g., EMG/nerve conduction studies and diagnostic blocks of the specific affected nerve(s)) and the specific nerve(s) to be stimulated are named; AND (5) trial of percutaneous stimulation was successful (resulting in at least a 50% reduction in pain for a minimum of 3 days); Peripheral nerve stimulation trial is limited to four leads with a maximum of 16 contacts; If a peripheral nerve stimulation trial fails, a repeat trial is NOT medically necessary UNLESS there are extenuating circumstances that led to trial failure; The SPRINT PNS System is a 60-day standalone device that does NOT require a trial of percutaneous stimulation; Revision/replacement of a previously implanted (peripheral nerve) stimulator is medically necessary for ANY of (ONE of): (1) lead malfunction (e.g., fracture or migration); OR (2) prior device removal for infection, with consult from an infectious disease specialist to confirm infection has been eradicated; OR (3) member has a documented need for an MRI-compatible device due to contraindications to CT/myelography or other immediate need and the device was providing pain relief previously; OR (4) the PNS battery/generator needs replacement for a member who experienced positive pain relief from the existing PNS and the current stimulator or battery/generator is no longer under warranty and cannot be repaired. Applies to 15 codes: E0720, E0730, E0731, A4556, A4557, A4558, A4595, 64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For TENS: 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; For continued TENS: attending physician must document that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time; There must be sufficient medical information in the medical record to demonstrate that all applicable coverage criteria are met; Neither a practitioner's order, a supplier-prepared statement, nor a practitioner's attestation by itself provides sufficient documentation of medical necessity; the medical record must support medical necessity and substantiate any supplier-prepared statement or attestation; Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves to determine an item is reasonable and necessary; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary; The SWO must contain all of: member's name or identification number; order date; general description of the item (HCPCS code, HCPCS code narrative, or brand name/model number); all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies that are separately billed (listed separately); HCPCS code and quantity for each item/service requested; treating practitioner name and NPI; treating practitioner's signature.
Trap
Policy exclusions and limitations: TENS is experimental, investigational, or unproven for acute pain (less than 3 months duration) other than post-operative pain; TENS is experimental, investigational, or unproven for acute and chronic headaches (inadequate scientific evidence to support efficacy); TENS is experimental, investigational, or unproven for adhesive capsulitis (frozen shoulder); TENS is experimental, investigational, or unproven for carpal tunnel syndrome pain; TENS is experimental, investigational, or unproven for cervicalgia (e.g., by means of the Quell device); TENS is experimental, investigational, or unproven for chemotherapy-induced peripheral neuropathy; TENS is experimental, investigational, or unproven for chondromalacia patellae and patellofemoral disorders; TENS is experimental, investigational, or unproven for chronic low back pain; TENS is experimental, investigational, or unproven for deep abdominal pain; TENS is experimental, investigational, or unproven for fibromyalgia; TENS is experimental, investigational, or unproven for hip fracture pain; TENS is experimental, investigational, or unproven for migraine; TENS is experimental, investigational, or unproven for musculoskeletal pain in hemophilia; TENS is experimental, investigational, or unproven for neuropathic pain; TENS is experimental, investigational, or unproven for pain management in burn persons; TENS is experimental, investigational, or unproven for pelvic pain; TENS is experimental, investigational, or unproven for peripheral arterial disease; TENS is experimental, investigational, or unproven for phantom pain; TENS is experimental, investigational, or unproven for post-total knee arthroplasty pain; TENS is experimental, investigational, or unproven for rotator cuff disease (e.g., calcific tendinitis, rotator cuff tendinitis, and subacromial impingement syndrome); TENS is experimental, investigational, or unproven for stump pain; TENS is experimental, investigational, or unproven for suprascapular nerve entrapment; TENS is experimental, investigational, or unproven for temporomandibular joint (TMJ) pain; Stellate ganglion blockade using TENS is experimental, investigational, or unproven; TENS with low level laser therapy (LLLT) (e.g., the Neurolumen device) for the treatment of Morton's neuroma and all other indications is experimental, investigational, or unproven; PENS (percutaneous electrical nerve stimulation) is experimental, investigational, or unproven for the management of opioid withdrawal, treatment of chronic neck pain, and all other indications (not adequately established); Combined PENS and dorsal root ganglion stimulation for the treatment of back pain is experimental, investigational, or unproven; Combined PENS and spinal cord stimulation is experimental, investigational, or unproven; IB-Stim for the treatment of irritable bowel syndrome, and treatment of nausea and abdominal pain secondary to irritable bowel syndrome, is experimental, investigational, or unproven; Peripheral nerve stimulation (e.g., Curonix Freedom, Nalu, SPRINT, StimRouter) is experimental, investigational, or unproven for all indications other than intractable neurogenic pain, including: chronic abdominal pain; Peripheral nerve stimulation for cluneal nerve for treatment of sacroiliac joint-mediated pain, back pain and other indications is experimental, investigational, or unproven; Peripheral nerve stimulation of the genicular nerves for knee pain (all indications) is experimental, investigational, or unproven; Peripheral nerve stimulation for intercostal neuralgia is experimental, investigational, or unproven; Medial branch nerve stimulation is experimental, investigational, or unproven; Peripheral nerve stimulation for occipital neuralgia and other headache types is experimental, investigational, or unproven; Peripheral nerve stimulation for post-herpetic neuralgia is experimental, investigational, or unproven; Saphenous nerve stimulation for knee pain is experimental, investigational, or unproven; Peripheral nerve stimulation for shoulder pain is experimental, investigational, or unproven; Peripheral nerve stimulation for suprascapular nerve entrapment is experimental, investigational, or unproven; Interferential stimulation (e.g., RS-4i Sequential Stimulator) for the reduction of pain and edema and all other indications is experimental, investigational, or unproven; Percutaneous neuromodulation therapy (e.g., Vertis PNT, BiowavePRO) for pain and other indications is experimental, investigational, or unproven; Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS) (e.g., the StimQ PNS System) for the treatment of chronic pain, hemiplegic shoulder pain, and other indications is experimental, investigational, or unproven; Accelerated recovery performance (ARP) wave therapy for the treatment of lumbar spondylosis/back pain is experimental, investigational, or unproven; H-WAVE type stimulators are experimental, investigational, or unproven for diabetic peripheral neuropathy and for ANY of the following: to accelerate healing; OR to reduce edema; OR to reduce pain from causes other than chronic diabetic peripheral neuropathy; OR to treat chronic pain due to ischemia; Microcurrent Electrical Nerve Stimulation (MENS) Therapy for the treatment of chronic back pain and all other indications is experimental, investigational, or unproven; Electroceutical Therapy (also known as bioelectric nerve block) for the treatment of acute pain or chronic pain is experimental, investigational, or unproven; Sympathetic therapy is experimental, investigational, or unproven; Intramuscular stimulation is experimental, investigational, or unproven; Electro-Acuscope / Myopulse / Equiscope is experimental, investigational, or unproven; Electroanalgesia is experimental, investigational, or unproven; Scrambler Therapy / The Calmare Therapy Device for the treatment of cancer pain, chronic pain, Dejerine-Roussy syndrome, neuropathic pain associated with chemotherapy-induced peripheral neuropathy, post-mastectomy pain, and other indications is experimental, investigational, or unproven; Non-Invasive Interactive Neurostimulation (e.g., the InterX 1000 neurostimulator device) for the treatment of chronic pain and other indications is experimental, investigational, or unproven; Auricular electrical stimulation (e.g., DyAnsys auricular electrical nerve stimulator) for the treatment of headache, low-back pain, neuropathic pain, and all other indications is experimental, investigational, or unproven; Combination stimulation devices are experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0011 — Electrical Stimulation for Pain (TENS/PENS)

Coverage criteria

  • TENS (transcutaneous electrical nerve stimulators) is medically necessary DME when used as an adjunct or alternative to drugs EITHER (ONE of): 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
  • TENS for acute post-operative or chronic intractable pain: device is medically necessary INITIALLY for a trial period of at least 1 month but not to exceed 2 months
  • Continued TENS after the 1-month trial is medically necessary IF (ALL): the treatment significantly alleviates pain; AND 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
  • TENS ordering physician must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit
  • Form-fitting conductive garment is medically necessary DME ONLY when (ALL of): FDA-approved for marketing; AND prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above; AND (ONE of the following): (1) member cannot manage without the conductive garment due to the large area or large number of sites to be stimulated and stimulation must be delivered so frequently that conventional electrodes/adhesive tapes/lead wires are not feasible; OR (2) member has a medical need for rehabilitation strengthening following an injury where the nerve supply to the muscle is intact; OR (3) member has a skin problem or other medical condition that precludes application of conventional electrodes/adhesive tapes/lead wires; OR (4) member requires electrical stimulation beneath a cast to treat disuse atrophy where the nerve supply to the muscle is intact
  • PENS (percutaneous electrical nerve stimulation) is medically necessary DME (ONE of): (1) up to a 30-day period for treatment of chronic low back pain secondary to degenerative disc disease when PENS is used as part of a multi-modality rehabilitation program that includes exercise; OR (2) treatment of diabetic neuropathy or neuropathic pain in members who failed to adequately respond to conventional treatments including three or more of the following groups of agents: anti-convulsants (e.g., pregabalin), anti-depressants (e.g., amitriptyline, duloxetine), opioids (e.g., morphine sulphate, tramadol), and other pharmacological agents (e.g., capsaicin, isosorbide dinitrate spray)
  • Peripherally implanted nerve stimulators (e.g., Curonix Freedom PNS, Nalu PNS, SPRINT PNS, StimRouter) are medically necessary DME for intractable neuropathic pain when ALL of: (1) member has chronic intractable pain refractory to other methods of treatment (e.g., analgesics and other medications including TCAs, SSRIs, SNRIs and antiseizure medications where appropriate, physical therapy in-person for at least 6 weeks in the past year, local injection, surgery); AND (2) member is not addicted to drugs (per American Society of Addiction Medicine guidelines); AND (3) there is no psychological contraindication to peripheral nerve stimulation (Note: formal psychological evaluation not required); AND (4) there is objective evidence of pathology (e.g., EMG/nerve conduction studies and diagnostic blocks of the specific affected nerve(s)) and the specific nerve(s) to be stimulated are named; AND (5) trial of percutaneous stimulation was successful (resulting in at least a 50% reduction in pain for a minimum of 3 days)
  • Peripheral nerve stimulation trial is limited to four leads with a maximum of 16 contacts
  • If a peripheral nerve stimulation trial fails, a repeat trial is NOT medically necessary UNLESS there are extenuating circumstances that led to trial failure
  • The SPRINT PNS System is a 60-day standalone device that does NOT require a trial of percutaneous stimulation
  • Revision/replacement of a previously implanted (peripheral nerve) stimulator is medically necessary for ANY of (ONE of): (1) lead malfunction (e.g., fracture or migration); OR (2) prior device removal for infection, with consult from an infectious disease specialist to confirm infection has been eradicated; OR (3) member has a documented need for an MRI-compatible device due to contraindications to CT/myelography or other immediate need and the device was providing pain relief previously; OR (4) the PNS battery/generator needs replacement for a member who experienced positive pain relief from the existing PNS and the current stimulator or battery/generator is no longer under warranty and cannot be repaired

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • For TENS: 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
  • For continued TENS: attending physician must document that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time
  • There must be sufficient medical information in the medical record to demonstrate that all applicable coverage criteria are met
  • Neither a practitioner's order, a supplier-prepared statement, nor a practitioner's attestation by itself provides sufficient documentation of medical necessity; the medical record must support medical necessity and substantiate any supplier-prepared statement or attestation
  • Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves to determine an item is reasonable and necessary
  • A new prescription from the treating practitioner is required each time a new device or repair is requisitioned
  • A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary
  • The SWO must contain all of: member's name or identification number; order date; general description of the item (HCPCS code, HCPCS code narrative, or brand name/model number); all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies that are separately billed (listed separately); HCPCS code and quantity for each item/service requested; treating practitioner name and NPI; treating practitioner's signature

Frequently asked questions

When does Aetna cover Electrical Stimulation for Pain (TENS/PENS) (CPT E0720), and what gets it denied?
Aetna covers TENS as DME for acute post-operative pain (first 30 days) or certain chronic intractable pain not responsive to other treatments, starting with a 1-2 month trial that must be documented as significantly relieving pain before continued use is approved; it also covers PENS for specific back pain and neuropathy situations and peripherally implanted nerve stimulators for intractable neuropathic pain when strict criteria (refractory pain, objective pathology, named nerve, and a successful >=50% percutaneous trial) are all met. A very long list of other indications and devices (e.g., TENS for most chronic/neuropathic pain conditions, interferential stimulation, microcurrent/MENS, Scrambler/Calmare, H-Wave, sympathetic therapy, auricular and peripheral field stimulation) is considered experimental/investigational and not covered. The bulletin is silent on precertification/prior authorization. Coverage criteria include: TENS (transcutaneous electrical nerve stimulators) is medically necessary DME when used as an adjunct or alternative to drugs EITHER (ONE of): 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; TENS for acute post-operative or chronic intractable pain: device is medically necessary INITIALLY for a trial period of at least 1 month but not to exceed 2 months; Continued TENS after the 1-month trial is medically necessary IF (ALL): the treatment significantly alleviates pain; AND 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; TENS ordering physician must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit; Form-fitting conductive garment is medically necessary DME ONLY when (ALL of): FDA-approved for marketing; AND prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above; AND (ONE of the following): (1) member cannot manage without the conductive garment due to the large area or large number of sites to be stimulated and stimulation must be delivered so frequently that conventional electrodes/adhesive tapes/lead wires are not feasible; OR (2) member has a medical need for rehabilitation strengthening following an injury where the nerve supply to the muscle is intact; OR (3) member has a skin problem or other medical condition that precludes application of conventional electrodes/adhesive tapes/lead wires; OR (4) member requires electrical stimulation beneath a cast to treat disuse atrophy where the nerve supply to the muscle is intact; PENS (percutaneous electrical nerve stimulation) is medically necessary DME (ONE of): (1) up to a 30-day period for treatment of chronic low back pain secondary to degenerative disc disease when PENS is used as part of a multi-modality rehabilitation program that includes exercise; OR (2) treatment of diabetic neuropathy or neuropathic pain in members who failed to adequately respond to conventional treatments including three or more of the following groups of agents: anti-convulsants (e.g., pregabalin), anti-depressants (e.g., amitriptyline, duloxetine), opioids (e.g., morphine sulphate, tramadol), and other pharmacological agents (e.g., capsaicin, isosorbide dinitrate spray); Peripherally implanted nerve stimulators (e.g., Curonix Freedom PNS, Nalu PNS, SPRINT PNS, StimRouter) are medically necessary DME for intractable neuropathic pain when ALL of: (1) member has chronic intractable pain refractory to other methods of treatment (e.g., analgesics and other medications including TCAs, SSRIs, SNRIs and antiseizure medications where appropriate, physical therapy in-person for at least 6 weeks in the past year, local injection, surgery); AND (2) member is not addicted to drugs (per American Society of Addiction Medicine guidelines); AND (3) there is no psychological contraindication to peripheral nerve stimulation (Note: formal psychological evaluation not required); AND (4) there is objective evidence of pathology (e.g., EMG/nerve conduction studies and diagnostic blocks of the specific affected nerve(s)) and the specific nerve(s) to be stimulated are named; AND (5) trial of percutaneous stimulation was successful (resulting in at least a 50% reduction in pain for a minimum of 3 days); Peripheral nerve stimulation trial is limited to four leads with a maximum of 16 contacts; If a peripheral nerve stimulation trial fails, a repeat trial is NOT medically necessary UNLESS there are extenuating circumstances that led to trial failure; The SPRINT PNS System is a 60-day standalone device that does NOT require a trial of percutaneous stimulation; Revision/replacement of a previously implanted (peripheral nerve) stimulator is medically necessary for ANY of (ONE of): (1) lead malfunction (e.g., fracture or migration); OR (2) prior device removal for infection, with consult from an infectious disease specialist to confirm infection has been eradicated; OR (3) member has a documented need for an MRI-compatible device due to contraindications to CT/myelography or other immediate need and the device was providing pain relief previously; OR (4) the PNS battery/generator needs replacement for a member who experienced positive pain relief from the existing PNS and the current stimulator or battery/generator is no longer under warranty and cannot be repaired. Applies to 15 codes: E0720, E0730, E0731, A4556, A4557, A4558, A4595, 64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For TENS: 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; For continued TENS: attending physician must document that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time; There must be sufficient medical information in the medical record to demonstrate that all applicable coverage criteria are met; Neither a practitioner's order, a supplier-prepared statement, nor a practitioner's attestation by itself provides sufficient documentation of medical necessity; the medical record must support medical necessity and substantiate any supplier-prepared statement or attestation; Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves to determine an item is reasonable and necessary; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary; The SWO must contain all of: member's name or identification number; order date; general description of the item (HCPCS code, HCPCS code narrative, or brand name/model number); all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies that are separately billed (listed separately); HCPCS code and quantity for each item/service requested; treating practitioner name and NPI; treating practitioner's signature. Policy exclusions and limitations: TENS is experimental, investigational, or unproven for acute pain (less than 3 months duration) other than post-operative pain; TENS is experimental, investigational, or unproven for acute and chronic headaches (inadequate scientific evidence to support efficacy); TENS is experimental, investigational, or unproven for adhesive capsulitis (frozen shoulder); TENS is experimental, investigational, or unproven for carpal tunnel syndrome pain; TENS is experimental, investigational, or unproven for cervicalgia (e.g., by means of the Quell device); TENS is experimental, investigational, or unproven for chemotherapy-induced peripheral neuropathy; TENS is experimental, investigational, or unproven for chondromalacia patellae and patellofemoral disorders; TENS is experimental, investigational, or unproven for chronic low back pain; TENS is experimental, investigational, or unproven for deep abdominal pain; TENS is experimental, investigational, or unproven for fibromyalgia; TENS is experimental, investigational, or unproven for hip fracture pain; TENS is experimental, investigational, or unproven for migraine; TENS is experimental, investigational, or unproven for musculoskeletal pain in hemophilia; TENS is experimental, investigational, or unproven for neuropathic pain; TENS is experimental, investigational, or unproven for pain management in burn persons; TENS is experimental, investigational, or unproven for pelvic pain; TENS is experimental, investigational, or unproven for peripheral arterial disease; TENS is experimental, investigational, or unproven for phantom pain; TENS is experimental, investigational, or unproven for post-total knee arthroplasty pain; TENS is experimental, investigational, or unproven for rotator cuff disease (e.g., calcific tendinitis, rotator cuff tendinitis, and subacromial impingement syndrome); TENS is experimental, investigational, or unproven for stump pain; TENS is experimental, investigational, or unproven for suprascapular nerve entrapment; TENS is experimental, investigational, or unproven for temporomandibular joint (TMJ) pain; Stellate ganglion blockade using TENS is experimental, investigational, or unproven; TENS with low level laser therapy (LLLT) (e.g., the Neurolumen device) for the treatment of Morton's neuroma and all other indications is experimental, investigational, or unproven; PENS (percutaneous electrical nerve stimulation) is experimental, investigational, or unproven for the management of opioid withdrawal, treatment of chronic neck pain, and all other indications (not adequately established); Combined PENS and dorsal root ganglion stimulation for the treatment of back pain is experimental, investigational, or unproven; Combined PENS and spinal cord stimulation is experimental, investigational, or unproven; IB-Stim for the treatment of irritable bowel syndrome, and treatment of nausea and abdominal pain secondary to irritable bowel syndrome, is experimental, investigational, or unproven; Peripheral nerve stimulation (e.g., Curonix Freedom, Nalu, SPRINT, StimRouter) is experimental, investigational, or unproven for all indications other than intractable neurogenic pain, including: chronic abdominal pain; Peripheral nerve stimulation for cluneal nerve for treatment of sacroiliac joint-mediated pain, back pain and other indications is experimental, investigational, or unproven; Peripheral nerve stimulation of the genicular nerves for knee pain (all indications) is experimental, investigational, or unproven; Peripheral nerve stimulation for intercostal neuralgia is experimental, investigational, or unproven; Medial branch nerve stimulation is experimental, investigational, or unproven; Peripheral nerve stimulation for occipital neuralgia and other headache types is experimental, investigational, or unproven; Peripheral nerve stimulation for post-herpetic neuralgia is experimental, investigational, or unproven; Saphenous nerve stimulation for knee pain is experimental, investigational, or unproven; Peripheral nerve stimulation for shoulder pain is experimental, investigational, or unproven; Peripheral nerve stimulation for suprascapular nerve entrapment is experimental, investigational, or unproven; Interferential stimulation (e.g., RS-4i Sequential Stimulator) for the reduction of pain and edema and all other indications is experimental, investigational, or unproven; Percutaneous neuromodulation therapy (e.g., Vertis PNT, BiowavePRO) for pain and other indications is experimental, investigational, or unproven; Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS) (e.g., the StimQ PNS System) for the treatment of chronic pain, hemiplegic shoulder pain, and other indications is experimental, investigational, or unproven; Accelerated recovery performance (ARP) wave therapy for the treatment of lumbar spondylosis/back pain is experimental, investigational, or unproven; H-WAVE type stimulators are experimental, investigational, or unproven for diabetic peripheral neuropathy and for ANY of the following: to accelerate healing; OR to reduce edema; OR to reduce pain from causes other than chronic diabetic peripheral neuropathy; OR to treat chronic pain due to ischemia; Microcurrent Electrical Nerve Stimulation (MENS) Therapy for the treatment of chronic back pain and all other indications is experimental, investigational, or unproven; Electroceutical Therapy (also known as bioelectric nerve block) for the treatment of acute pain or chronic pain is experimental, investigational, or unproven; Sympathetic therapy is experimental, investigational, or unproven; Intramuscular stimulation is experimental, investigational, or unproven; Electro-Acuscope / Myopulse / Equiscope is experimental, investigational, or unproven; Electroanalgesia is experimental, investigational, or unproven; Scrambler Therapy / The Calmare Therapy Device for the treatment of cancer pain, chronic pain, Dejerine-Roussy syndrome, neuropathic pain associated with chemotherapy-induced peripheral neuropathy, post-mastectomy pain, and other indications is experimental, investigational, or unproven; Non-Invasive Interactive Neurostimulation (e.g., the InterX 1000 neurostimulator device) for the treatment of chronic pain and other indications is experimental, investigational, or unproven; Auricular electrical stimulation (e.g., DyAnsys auricular electrical nerve stimulator) for the treatment of headache, low-back pain, neuropathic pain, and all other indications is experimental, investigational, or unproven; Combination stimulation devices are experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Electrical Stimulation for Pain (TENS/PENS)?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For TENS: 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; For continued TENS: attending physician must document that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time; There must be sufficient medical information in the medical record to demonstrate that all applicable coverage criteria are met; Neither a practitioner's order, a supplier-prepared statement, nor a practitioner's attestation by itself provides sufficient documentation of medical necessity; the medical record must support medical necessity and substantiate any supplier-prepared statement or attestation; Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves to determine an item is reasonable and necessary; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills without first receiving a completed SWO, the claim is denied as not medically necessary; The SWO must contain all of: member's name or identification number; order date; general description of the item (HCPCS code, HCPCS code narrative, or brand name/model number); all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies that are separately billed (listed separately); HCPCS code and quantity for each item/service requested; treating practitioner name and NPI; treating practitioner's signature.
What does Aetna exclude for Electrical Stimulation for Pain (TENS/PENS)?
Policy exclusions and limitations: TENS is experimental, investigational, or unproven for acute pain (less than 3 months duration) other than post-operative pain; TENS is experimental, investigational, or unproven for acute and chronic headaches (inadequate scientific evidence to support efficacy); TENS is experimental, investigational, or unproven for adhesive capsulitis (frozen shoulder); TENS is experimental, investigational, or unproven for carpal tunnel syndrome pain; TENS is experimental, investigational, or unproven for cervicalgia (e.g., by means of the Quell device); TENS is experimental, investigational, or unproven for chemotherapy-induced peripheral neuropathy; TENS is experimental, investigational, or unproven for chondromalacia patellae and patellofemoral disorders; TENS is experimental, investigational, or unproven for chronic low back pain; TENS is experimental, investigational, or unproven for deep abdominal pain; TENS is experimental, investigational, or unproven for fibromyalgia; TENS is experimental, investigational, or unproven for hip fracture pain; TENS is experimental, investigational, or unproven for migraine; TENS is experimental, investigational, or unproven for musculoskeletal pain in hemophilia; TENS is experimental, investigational, or unproven for neuropathic pain; TENS is experimental, investigational, or unproven for pain management in burn persons; TENS is experimental, investigational, or unproven for pelvic pain; TENS is experimental, investigational, or unproven for peripheral arterial disease; TENS is experimental, investigational, or unproven for phantom pain; TENS is experimental, investigational, or unproven for post-total knee arthroplasty pain; TENS is experimental, investigational, or unproven for rotator cuff disease (e.g., calcific tendinitis, rotator cuff tendinitis, and subacromial impingement syndrome); TENS is experimental, investigational, or unproven for stump pain; TENS is experimental, investigational, or unproven for suprascapular nerve entrapment; TENS is experimental, investigational, or unproven for temporomandibular joint (TMJ) pain; Stellate ganglion blockade using TENS is experimental, investigational, or unproven; TENS with low level laser therapy (LLLT) (e.g., the Neurolumen device) for the treatment of Morton's neuroma and all other indications is experimental, investigational, or unproven; PENS (percutaneous electrical nerve stimulation) is experimental, investigational, or unproven for the management of opioid withdrawal, treatment of chronic neck pain, and all other indications (not adequately established); Combined PENS and dorsal root ganglion stimulation for the treatment of back pain is experimental, investigational, or unproven; Combined PENS and spinal cord stimulation is experimental, investigational, or unproven; IB-Stim for the treatment of irritable bowel syndrome, and treatment of nausea and abdominal pain secondary to irritable bowel syndrome, is experimental, investigational, or unproven; Peripheral nerve stimulation (e.g., Curonix Freedom, Nalu, SPRINT, StimRouter) is experimental, investigational, or unproven for all indications other than intractable neurogenic pain, including: chronic abdominal pain; Peripheral nerve stimulation for cluneal nerve for treatment of sacroiliac joint-mediated pain, back pain and other indications is experimental, investigational, or unproven; Peripheral nerve stimulation of the genicular nerves for knee pain (all indications) is experimental, investigational, or unproven; Peripheral nerve stimulation for intercostal neuralgia is experimental, investigational, or unproven; Medial branch nerve stimulation is experimental, investigational, or unproven; Peripheral nerve stimulation for occipital neuralgia and other headache types is experimental, investigational, or unproven; Peripheral nerve stimulation for post-herpetic neuralgia is experimental, investigational, or unproven; Saphenous nerve stimulation for knee pain is experimental, investigational, or unproven; Peripheral nerve stimulation for shoulder pain is experimental, investigational, or unproven; Peripheral nerve stimulation for suprascapular nerve entrapment is experimental, investigational, or unproven; Interferential stimulation (e.g., RS-4i Sequential Stimulator) for the reduction of pain and edema and all other indications is experimental, investigational, or unproven; Percutaneous neuromodulation therapy (e.g., Vertis PNT, BiowavePRO) for pain and other indications is experimental, investigational, or unproven; Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS) (e.g., the StimQ PNS System) for the treatment of chronic pain, hemiplegic shoulder pain, and other indications is experimental, investigational, or unproven; Accelerated recovery performance (ARP) wave therapy for the treatment of lumbar spondylosis/back pain is experimental, investigational, or unproven; H-WAVE type stimulators are experimental, investigational, or unproven for diabetic peripheral neuropathy and for ANY of the following: to accelerate healing; OR to reduce edema; OR to reduce pain from causes other than chronic diabetic peripheral neuropathy; OR to treat chronic pain due to ischemia; Microcurrent Electrical Nerve Stimulation (MENS) Therapy for the treatment of chronic back pain and all other indications is experimental, investigational, or unproven; Electroceutical Therapy (also known as bioelectric nerve block) for the treatment of acute pain or chronic pain is experimental, investigational, or unproven; Sympathetic therapy is experimental, investigational, or unproven; Intramuscular stimulation is experimental, investigational, or unproven; Electro-Acuscope / Myopulse / Equiscope is experimental, investigational, or unproven; Electroanalgesia is experimental, investigational, or unproven; Scrambler Therapy / The Calmare Therapy Device for the treatment of cancer pain, chronic pain, Dejerine-Roussy syndrome, neuropathic pain associated with chemotherapy-induced peripheral neuropathy, post-mastectomy pain, and other indications is experimental, investigational, or unproven; Non-Invasive Interactive Neurostimulation (e.g., the InterX 1000 neurostimulator device) for the treatment of chronic pain and other indications is experimental, investigational, or unproven; Auricular electrical stimulation (e.g., DyAnsys auricular electrical nerve stimulator) for the treatment of headache, low-back pain, neuropathic pain, and all other indications is experimental, investigational, or unproven; Combination stimulation devices are experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0011 — Electrical Stimulation for Pain (TENS/PENS)

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0011 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.