CurrentHighmark PennsylvaniaPolicy N/A

Transcutaneous Electrical Nerve Stimulation (TENS) prior authorization form

This document is a prior authorization/fax request form used by Highmark Pennsylvania for assessing medical necessity of TENS device use for acute postoperative or chronic intractable pain. It is completed by the requesting provider and relates to member-specific clinical information needed for coverage decisions.

Policy Summary

PayerHighmark Pennsylvania

PolicyTENS prior authorization form (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with a typed office note documenting prior treatments tried and a successful 30-day TENS trial when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30minimum documented successful TENS trial duration queried

99code for 'forever' estimated length of need on form

1typed office note required

Coverage Criteria

The form asks the requester to indicate applicability for certain items using the key Y (Yes), N (No), or D (Does not apply). While several clinical questions on the form include the D option, the document does not enumerate any explicit exclusion conditions tied to that response—D simply records that the question is not applicable to the member’s situation.

Coding and Key Values

TENS trial duration — inv-02

Minimum documented successful TENS trial duration>= 30 days

Form field asking about successful trialHas there been a successful trial usage (of TENS) for a minimum of 30 days? — response options: Y / N / D

Where recordedAnswered on the prior authorization form under 'Additional Clinical Rationale' item 7

Provider Submission & Documentation Requirements

Policy Summary

PayerHighmark Pennsylvania

PolicyTENS prior authorization form (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with a typed office note documenting prior treatments tried and a successful 30-day TENS trial when applicable.

SourceLink

On This Page

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Prior Authorization

Prior Authorization Submission Requirements

Prior authorization is required. Submit a completed prior authorization form and a typed office note that addresses items 1–7 on the form (see list below). Include the Medical Management & Policy fax number or contact details per payer instructions when submitting.

Submit completed prior authorization form
Include typed office note addressing items 1–7

Documentation Required

Conservative Therapy Documentation

Provide documentation of conservative therapy tried and failed prior to approval. The submission must list other treatments attempted (e.g., medications, physical therapy, injections, bracing) and document lack of adequate response or intolerance.

List other treatments tried and failed
Describe duration and response to each prior treatment

Documentation Required

Required Documentation

Required documentation includes a typed office note with pertinent clinical information and a fully completed form. The form should indicate whether pain is acute post‑operative or chronic intractable and include details requested in items 1–7 (see form content).

Typed office note with pertinent information
Completed form fields including acute post-operative vs chronic intractable status and all items 1–7

Denial Risk

Documentation Omissions May Cause Denial

Failure to provide a typed office note or to fully complete the requested clinical rationale (items 1–7, including prior treatments tried and dates) may result in denial of the request. Omissions or incomplete responses (including missing dates, missing trial documentation, or absent physician signature) can delay processing or cause denial.

Incomplete or missing typed office note may cause denial
Omitted responses to items 1–7 (including prior treatments, dates, trial of TENS) may cause denial

Conservative Treatment Requirements

Document prior treatments tried and failed

Provider must list conservative treatments previously tried and indicate failures; this information is required as part of the clinical rationale for prior authorization.

ALL of the following

ONE of
- Typed office note with pertinent information is submitted (provider must include clinical rationale).
- Provider documents whether pain is acute post‑operative, chronic intractable, or not applicable (Y/N/D) and provides date of surgery when applicable.
- Provider documents duration of intractable pain in months when applicable.
Provider lists other treatment(s) that have been tried and failed (free‑text field on form).
Provider indicates estimated length of need (in months) (use 99 for 'forever' if applicable).
If applicable, provider documents whether there has been a successful trial usage of TENS for a minimum of 30 days (Y/N/D).

ALL of the following

A completed form including the prior treatments tried/failed field and supporting typed office note is provided.

Definitions

Successful TENS trial — inv-08

Definition of successful TENS trialA documented trial usage of TENS for a minimum of 30 days as indicated on the form.

Form question locationItem 7 on the form: 'Has there been a successful trial usage (of TENS) for a minimum of 30 days? (Y/N/D)'

Documentation required to support responseDate of trial and requesting provider signature and date recorded on the form and supported by a typed office note.

Background

The form separates acute post‑operative pain and chronic, intractable pain and requests specific clinical detail for each. For acute post‑operative pain the form asks the date of the surgery. For chronic, intractable pain the form requests the type or cause and the duration in months. The requester must also list other treatments that have been tried and failed as part of the clinical rationale, provide an estimated length of need in months (use 99 to indicate “forever”), and indicate whether there has been a successful TENS trial of at least 30 days.

Imaging Requirements

Note

TENS trial documentation: minimum 30‑day trial required (form query)

For TENS requests, the form explicitly asks whether there has been a successful trial usage of TENS for a minimum of 30 days; document this trial (Y/N/D) on item 7 and support it in the typed office note.

Indicate on item 7 whether a minimum 30‑day TENS trial was successful.
Include dates or documentation of the trial in the typed office note.