CurrentHighmark Blueshield NenyPolicy N/A

Certificate of Medical Necessity (CMN) for TENS unit

A CMN form to document clinical information supporting medical necessity for a transcutaneous electrical nerve stimulation (TENS) unit, including acute post-operative pain, chronic intractable pain, prior treatments tried, trial usage, and estimated length of need.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity (CMN) for TENS unit

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionSubmit a typed office note with pertinent information and complete the CMN fields (pain type, duration, prior treatments, estimated length of need, trial usage date, patient identifiers) and obtain physician signature (no stamps).

POLICY UPDATE CHANGES

No material clinical or coverage changes.

1Form Revision

CURRENTStatus

Certificate of Medical Necessity (CMN) for TENS unit — Overview

This is a Certificate of Medical Necessity (CMN) form for a Transcutaneous Electrical Nerve Stimulation (TENS) unit (Rev. 06/28/2011) intended to collect required clinical information to support coverage decisions for TENS therapy for acute post-operative or chronic intractable pain. The CMN documents clinical justification for durable medical equipment and captures items such as pain type, duration, prior treatments tried, trial usage, estimated length of need, and patient identifiers.

Requested information / Clinical Criteria (CMN fields)

Requested Information / Clinical Criteria

Document the following clinical items to support medical necessity for a TENS unit:

Requested Information / Clinical Criteria - Top Level

Patient Identifying Information: Patient identifying information: Patient name and ID number required.
Typed Office Note: Typed office note with pertinent information is provided.
Acute Post-Operative Pain
- Response Options (Acute): Response options: Y (Yes), N (No), D (Does not apply)
- Surgery Date: If Yes: provide date of surgery resulting in acute post-operative pain.date
  Date required when acute post-operative pain is affirmed.
Chronic Intractable Pain
- Response Options (Chronic): Response options: Y (Yes), N (No), D (Does not apply)
- Describe Cause: If Yes: describe the type or cause of the chronic, intractable pain.
- Duration of Intractable Pain: How long has the patient had intractable pain? (indicate number of months)numeric months
Prior Therapies Attempted: What other treatment(s) have been tried and failed?
Provide prior conservative/alternative therapies attempted.
Estimated Length of Need: Estimated length of need (in months)numeric months; 99 = forever
Successful Trial Usage
- Response Options (Trial): Response options: Y (Yes), N (No), D (Does not apply)
- Trial Date and Signature: If Yes: provide date of trial, and requesting provider signature details.date
  Provide trial date and requesting provider signature.
Provider Signature: Provider/physician signature and date required (stamps are not acceptable).

Form Identification: Certificate of Medical Necessity (CMN) for TENS unit (Rev. 06/28/2011)

Actionable provider requirements

Documentation Required

Provide typed office note and CMN details

Submit a typed office note with pertinent information and complete the CMN fields (pain type, duration, prior treatments, estimated length of need, trial usage date, patient identifiers) and obtain physician signature (no stamps).

Pain type (acute post-operative or chronic, intractable; if chronic, describe type or cause)
Duration of pain (number of months for intractable pain)
Prior treatments tried and failed
Estimated length of need (in months; 99 = forever)
Date of trial usage (if successful trial of minimum 30 days)
Patient identifying information (patient name and ID number)
Physician signature and date (stamps are not acceptable)

Prior Authorization

Support for medical necessity

Use this CMN to document clinical rationale required by payer to determine medical necessity for TENS unit coverage (including documentation of trial usage and prior treatment failures).

Document trial usage date and that the trial met the minimum 30-day requirement
Document prior conservative/alternative therapies attempted and failures on the CMN

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity (CMN) for TENS unit

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

On This Page

OpenPayer

Certificate of Medical Necessity (CMN) for TENS unit

Certificate of Medical Necessity (CMN) for TENS unit — Overview

Requested information / Clinical Criteria (CMN fields)

Actionable provider requirements

Key thresholds and duration rules

Background and definitions

Revision history