Description

Transcutaneous electrical nerve stimulation (TENS) and/or neuromuscular electrical stimulation (NMES) can ordinarily be delivered to individuals through the use of conventional electrodes, adhesive tapes and lead wires. There may be times, however, when it is medically necessary for certain individuals receiving TENS or NMES treatment to use a form-fitting conductive garment (i.e., a garment with conductive fibers which are separated from the individual’s skin by layers of fabric). This conductive garment is worn as an alternative to conventional electrodes, adhesive tapes and lead wires.

Criteria

A form-fitting conductive garment and related supplies may be considered medically necessary when:

• The garment has received permission or approval for marketing by the Food and Drug Administration; and
• The garment has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and
• ANY ONE of the medical indications outlined below is met:
  • The individual cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires; or
  • The individual cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; or
  • The individual has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires; or
  • The individual requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve supply to the muscle is intact, or to treat chronic intractable pain; or
  • The individual has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact.

A conductive garment is considered not medically necessary for use with a TENS device during the two month trial period unless:

• There is documentation of a skin problem that existed prior to the start of the trial period; or
• A medical review establishes that use of a conductive garment is medically necessary for the individual.

Procedure Codes

Diagnosis Codes

NA

Professional Statements and Societal Positions Guidelines

NA