CurrentnorthwoodPolicy N/A

Transcutaneous Electrical Nerve Stimulators (TENS)

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Coverage and medical necessity criteria for TENS devices and related supplies for treatment of acute post-operative pain, chronic intractable pain, and chronic low back pain for Northwood members.

Policy Summary

Payernorthwood

PolicyTranscutaneous Electrical Nerve Stimulators (TENS)

Policy CodePolicy N/A

Change TypeAnnual review — no material change

Effective DateJan 1, 2023

Next Review DateFeb 5, 2024

Key ActionDo not submit Certificate of Medical Necessity (CMN) or DIF forms with claims for dates of service on or after 2023-01-01; such claims will be rejected.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30rental limit (days)

>=3 momin chronic duration

1-2 motrial rental

A4595supply code

K1016

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CurrentnorthwoodPolicy N/A

Transcutaneous Electrical Nerve Stimulators (TENS)

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Sign up for all northwood policy alerts

Know when northwood releases new policies or updates existing guidance.

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Coverage and medical necessity criteria for TENS devices and related supplies for treatment of acute post-operative pain, chronic intractable pain, and chronic low back pain for Northwood members.

Policy Summary

Payernorthwood

PolicyTranscutaneous Electrical Nerve Stimulators (TENS)

Policy CodePolicy N/A

Change TypeAnnual review — no material change

Effective DateJan 1, 2023

Next Review DateFeb 5, 2024

Key ActionDo not submit Certificate of Medical Necessity (CMN) or DIF forms with claims for dates of service on or after 2023-01-01; such claims will be rejected.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30rental limit (days)

>=3 momin chronic duration

1-2 motrial rental

A4595supply code

K1016

not requiredCMN policy

Coverage Criteria for TENS

I. Acute Post-operative Pain

Covered when ANY of the following are met:

Acute Post-operative Pain: TENS is covered for acute post-operative pain; coverage limited to 30 days (one month's rental) from the day of surgery; payment made only as a rental.30 days

TENS denied as not reasonable and necessary for acute pain <3 months duration other than post-operative

II. Chronic Pain Other than Low Back Pain

Covered when ALL of the following are met:

Chronic Pain Other than Low Back Pain: 1) The presumed etiology of the pain is a type accepted as responding to TENS (examples of conditions not considered reasonable/necessary include headache, visceral abdominal pain, pelvic pain, temporomandibular joint pain). 2) Pain present for at least three months. 3) Other appropriate treatment modalities have been tried and failed.>=3 months

A monitored trial rental of minimum 30 days and maximum 60 days is required; trial must be monitored by the treating practitioner; purchase requires practitioner determination of likely long‑term benefit.

III. Chronic Low Back Pain (CLBP)

Covered when ALL of the following are met:

Chronic Low Back Pain (CLBP): The member has one of the diagnosis codes listed in the Diagnosis Codes that Support Medical Necessity (Group 1 ICD‑10 codes) section of this policy.ICD-10 in Group 1 list required

TENS for CLBP does not require a trial rental period or assessment of effectiveness by the treating practitioner.

Initial coverage support (diagnosis linkage)

Covered when ALL of the following are met

Diagnosis: Claim includes a Group 1 ICD-10 diagnosis from the enumerated lumbar/lumbosacral codes that support medical necessity for chronic low back pain (CLBP).ICD‑10 in Group 1 list

See enumerated Group 1 ICD‑10 codes in the policy (lumbar/lumbosacral diagnoses).

Diagnosis support and investigational device coverage

Coverage determinations reference lists of ICD-10 codes for CLBP; other uses and certain devices are considered investigational or lack specified supporting codes.

CLBP coding support: For TENS used for chronic low back pain (CLBP), only the ICD‑10 codes specified in the policy (Group 1) support medical necessity; ICD‑10 codes not listed do not support medical necessity for CLBP.

See ICD‑10 code group listing in this policy.

Other TENS uses: For other uses of TENS (acute post‑operative pain, chronic pain other than CLBP) there are no specified diagnosis codes enumerated in the policy to support medical necessity (Group 2: N/A).

Use the clinical criteria in sections I and II for those indications.

Experimental devices: NOVOTTF (E0766) is considered experimental and investigational and is not a covered benefit; items such as the Cefaly device (A9270) serving a prevention purpose are non‑covered per policy.

See device/HCPCS guidance in policy.

General coverage determination

Coverage determinations

General coverage determination logic: Coverage determinations are made on a case‑by‑case basis and are subject to the member's contract, including terms, conditions, limitations, and exclusions; the clinical criteria are guidelines but the contract language prevails.

Northwood follows applicable CMS NCDs/LCDs as applicable.

Conditions identified in the policy as not reasonable and necessary for TENS include certain pain types that are unlikely to respond to TENS therapy. Examples enumerated by the policy include headache, visceral abdominal pain, pelvic pain, and temporomandibular joint (TMJ) pain. The policy also identifies certain device codes as experimental; specifically, devices and their monthly supplies billed to HCPCS K1016 (transcutaneous electrical nerve stimulator for stimulation of the trigeminal nerve) are considered experimental/investigational and noncovered.

The policy explicitly states that devices and monthly supplies billed to HCPCS code K1016 (a TENS device intended for stimulation of the trigeminal nerve) are considered experimental/investigational and noncovered. Claims for that device and its monthly supplies may be denied on that basis.

The NOVOTTF Tumor Treating Fields system (HCPCS E0766) is identified in the policy as experimental and investigational and not a covered benefit for glioblastoma and for other malignant tumors because effectiveness has not been established. The Cefaly device (HCPCS A9270 / Cephaly) — a forehead-applied TENS intended for prophylactic treatment of episodic migraine — is noted in the policy history and is described as an example of an item that serves a prevention purpose; such prevention/precautionary devices are designated as non-covered.

Equipment that is used primarily and customarily for a non-medical purpose is excluded from coverage because it is not considered durable medical equipment. The policy cites HCPCS E0766 (NOVOTTF Tumor Treating Fields system) in the context of devices identified as experimental/not covered, and states that items not meeting the definition of DME are excluded from coverage.

TENS therapy for chronic pain or for chronic low back pain that does not meet the policy's documented coverage criteria will be denied as not reasonable and necessary. Additionally, a TENS unit will be denied as not reasonable and necessary for acute non‑postoperative pain of less than three months' duration (that is, acute pain other than post‑operative pain).

The policy reiterates that the use of HCPCS K1016 and its associated monthly supplies is considered not covered (experimental/investigational). Claims for that code and supplies are treated as noncovered per the policy statement.

For TENS prescribed for chronic low back pain (CLBP), medical necessity is supported only when the claim includes one of the ICD‑10 diagnosis codes specifically listed in the policy's Group 1 diagnosis list. The policy states that ICD‑10 codes not specified in the CLBP list do not support medical necessity, and likewise for other TENS uses there are no specified supporting diagnosis codes in the policy.

Historical policy notes record that the Cefaly (Cephaly) device (HCPCS A9270) was added to the policy and discussed in prior revisions with respect to prophylactic episodic migraine and was noted as non‑covered for prophylactic use. The history also references E0766 (NOVOTTF) being identified in earlier revisions as experimental/not covered.

Codes and Billing (HCPCS / ICD-10)

Group 1 CodesHCPCS

E0720	DEVICE, TWO LEAD, LOCALIZED STIMULATION TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION.
E0731	FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)

Group 2 Codes (Supplies)HCPCSCovered

A4557	LEAD WIRES, (E.G., APNEA MONITOR), PER PAIR
A4595	ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)

Noncovered HCPCS Codes (Experimental/Investigational)HCPCSNot Covered

K1016

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR FOR ELECTRICAL STIMULATION OF THE TRIGEMINAL NERVE

Supplies HCPCSHCPCS

A4557	LEAD WIRES, (E.G., APNEA MONITOR), PER PAIR
A4595	ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)

Noncovered HCPCS Codes - Experimental/InvestigationalHCPCSNot Covered

K1016

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR FOR ELECTRICAL STIMULATION OF THE TRIGEMINAL NERVE

Group 1 ICD-10 Codes that Support Medical NecessityICD-10Covered

M40.36	Flatback syndrome, lumbar region
M40.37	Flatback syndrome, lumbosacral region
M40.46	Postural lordosis, lumbar region
M40.47	Postural lordosis, lumbosacral region
M40.56	Lordosis, unspecified, lumbar region
M40.57	Lordosis, unspecified, lumbosacral region
M41.26	Other idiopathic scoliosis, lumbar region
M41.27	Other idiopathic scoliosis, lumbosacral region
M41.56	Other secondary scoliosis, lumbar region
M41.57	Other secondary scoliosis, lumbosacral region

1–10 of 70

1/7

ICD-10 Codes listed in policy for CLBP-related supportICD-10

S32.032A	Unstable burst fracture of third lumbar vertebra, initial encounter for closed fracture
S32.032B	Unstable burst fracture of third lumbar vertebra, initial encounter for open fracture
S32.032D	Unstable burst fracture of third lumbar vertebra, subsequent encounter for fracture with routine healing
S32.032G	Unstable burst fracture of third lumbar vertebra, subsequent encounter for fracture with delayed healing
S32.032K	Unstable burst fracture of third lumbar vertebra, subsequent encounter for fracture with nonunion
S32.038A	Unstable burst fracture of third lumbar vertebra, sequela / Other fracture of third lumbar vertebra, initial encounter for closed fracture
S32.038B	Unstable burst fracture of third lumbar vertebra, sequela / Other fracture of third lumbar vertebra, initial encounter for open fracture
S32.038K	Unstable burst fracture of third lumbar vertebra, sequela = with nonunion
S32.039A	Unstable burst fracture of third lumbar vertebra, sequela = Unspecified fracture of third lumbar vertebra, initial encounter for closed
S32.039B	Unstable burst fracture of third lumbar vertebra, sequela = Unspecified fracture of third lumbar vertebra, initial encounter for open

1–10 of 72

1/8

Other device HCPCS codesHCPCSNot Covered

E0766	NOVOTTF - Tumor Treating Fields system
A9270	Cephaly device (example TENS device billing code)

Codes mentioned in policy history or coverage statementsHCPCS

A9270	Cefaly device (TENS applied to forehead) — referenced as added to policy; noted non-covered for prophylactic episodic use in past revision context
E0766	Electrical stimulation device used for cancer treatment — noted as experimental and investigational/not covered (per historical entry)
K1016	HCPCS code added and considered experimental and investigational (per 9-13-22 entry)
K1017	HCPCS code added and considered experimental and investigational (per 9-13-22 entry)

TENS trial and supplies

TENS trial duration (chronic non-CLBP)Minimum 30 days (1 month), maximum 60 days (2 months); trial paid as rental and must be monitored by treating practitioner to assess effectiveness

4‑lead order documentationIf a 4‑lead TENS unit is ordered, medical record must document why 2 leads are insufficient

Supply allowances (A4595)2‑lead: max 1 unit A4595 per month; 4‑lead: max 2 units A4595 per month; reduce billing frequency proportionally if use is < daily

Lead wire replacement (A4557)Replacement more often than every 12 months would rarely be reasonable and necessary

Trial-to-purchase requirement

Provider Requirements, Documentation, and Prior Authorization

Prior Authorization

Prior authorization and clinical-criteria requirement

Coverage/payment requires that the requested TENS service meet the policy clinical criteria (acute post‑operative rules, chronic pain criteria, or CLBP diagnosis list). Trial rental and documentation rules apply for chronic pain and covered claims; supplies are reimbursed only when provided with a covered TENS unit.

Prior authorization may be required per payer procedures when using covered HCPCS (see payer PA rules).
Trial rental period for chronic non‑CLBP must be monitored by the treating practitioner to determine effectiveness.

Billing Rule

Supply codes and noncovered experimental code

A4557 and A4595 are the HCPCS supply codes listed for TENS lead wires and monthly supplies; HCPCS code K1016 and its monthly supplies are identified as noncovered (experimental/investigational).

Conservative Therapy and Trial Requirements

failed conservative therapies and documented trial effectiveness — minimum 30 days, maximum 60 days (trial)

Failed conservative therapies and documented trial effectiveness: Other appropriate treatment modalities must have been tried and failed prior to coverage for chronic non‑low‑back pain; a monitored trial rental of minimum 30 days and maximum 60 days is required and the treating practitioner must document effectiveness during the trial.minimum 30 days, maximum 60 days

Trial rental will be paid as a rental; practitioner must document monitoring and outcome; purchase requires documented likely long‑term benefit.

Policy ties TENS (E0720, E0730) use to CLBP when requirements are met; conservative-treatment linkage implied

TENS (E0720, E0730) linkage to CLBP: TENS devices billed with E0720/E0730 must be linked to a supported Group 1 ICD‑10 diagnosis when used for CLBP; documentation must support one of the listed diagnoses to establish medical necessity.Group 1 ICD‑10 required for CLBP claims

Rental Periods and Supply Limits

inv-56: TENS rental — acute post-operative pain

Rental periodMaximum 30 days rental for acute post-operative pain (one month's rental)

Payment typePayment will be made only as a rental for the 30-day post-op period

Indication limitTENS denied for acute pain <3 months duration other than post-operative pain

inv-57: TENS supplies — A4595 monthly limits

A4595 monthly allowance2-lead: maximum one unit of A4595 per month; 4-lead: maximum two units of A4595 per month

Lead wires frequencyReplacement lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary

Imaging and Diagnostic Requirements

Note

Services and Devices Not Covered

The policy's Not Covered statements include TENS for acute non‑postoperative pain of less than three months' duration (i.e., acute pain other than post‑operative pain). In addition, devices and supplies billed to HCPCS K1016 are identified as experimental/investigational and therefore noncovered.

Background and Rationale

A transcutaneous electrical nerve stimulator (TENS unit) delivers electrical current through electrodes placed on the skin to reduce a patient's perception of pain by inhibiting transmission of afferent pain nerve impulses and/or by stimulating endorphin release. The policy further distinguishes TENS units from neuromuscular stimulators, which directly stimulate muscles or motor nerves. Indications and coverage depend on pain chronicity and etiology and whether the use meets the policy's trial and documentation requirements.

Definitions

inv-47: TENS unit — definition

DefinitionA transcutaneous electrical nerve stimulator (TENS) unit delivers electrical current through skin electrodes to decrease perception of pain by inhibiting afferent pain impulse transmission and/or stimulating endorphin release

PlacementElectrodes are placed on the surface of the skin

Distinct from other stimulatorsMust be distinguished from neuromuscular stimulators that directly stimulate muscles or motor nerves

inv-48: Neuromuscular stimulator — distinction from TENS

DistinctionNeuromuscular stimulators directly stimulate muscles and/or motor nerves and are distinct from TENS units

Function differenceTENS modulates pain perception via afferent nerve impulse inhibition or endorphin release rather than muscle activation

Policy Revision History

2006-11-20initial_release

Initial release of the TENS policy (prepared/reviewed by Rosanne Brugnoni; approved by Ken Fasse).

2014-11-20update

Effective 2014-01-01 added E0766 (NOVOTTF) noted as experimental/investigational and non-covered; also added A9270 (Cephaly) and ACA 6407 requirements referenced in the policy history entry.

2015-12-17annual_review

Annual review with updates to align policy with Medicare criteria and addition of ICD-10 codes and references.

Policy Summary

Payernorthwood

PolicyTranscutaneous Electrical Nerve Stimulators (TENS)

Policy CodePolicy N/A

Change TypeAnnual review — no material change

Effective DateJan 1, 2023

Next Review DateFeb 5, 2024

Key ActionDo not submit Certificate of Medical Necessity (CMN) or DIF forms with claims for dates of service on or after 2023-01-01; such claims will be rejected.

SourceLink

On This Page

Purchase requires treating practitioner determination that member is likely to derive significant long‑term therapeutic benefit after monitored trial

Linkage requirement for CLBP (E0720, E0730)

CLBP device codes requiredTENS billing codes E0720 and E0730 must be linked to a Group 1 ICD‑10 diagnosis from the policy when requirements for CLBP are met

Group 1 linkage referenceSee 'ICD‑10 Codes that Support Medical Necessity — Group 1' for the enumerated lumbar/lumbosacral diagnoses that support CLBP coverage

No trial required for CLBPWhen used for CLBP per section III, TENS does not require a trial rental period or assessment of effectiveness by the treating practitioner

Face-to-face exam and documentation (ACA 6407)

Face‑to‑face exam windowTreating practitioner must conduct a face‑to‑face examination within the six months preceding the written order (ACA 6407)

Documentation receipt prior to deliveryDocumentation describing the medical condition for which DME is prescribed must be received by the provider prior to delivery for certain DME items

Documentation contentDocumentation must describe the medical condition for which the DME is being prescribed

A4557 — lead wires, per pair
A4595 — electrical stimulator supplies, 2 lead, per month
K1016 — noncovered (transcutaneous stimulator for trigeminal nerve) and associated monthly supplies

Billing Rule

CMN submission and claim rejection policy

Do not submit Certificates of Medical Necessity (CMNs) or DIFs with claims for dates of service on or after January 1, 2023; claims received with these forms attached will be rejected and returned.

For claims with dates of service prior to 2023-01-01, submit the CMN/DIF with the claim if required or ensure it is on file with a prior claim.

Note

Coverage and prior authorization overview — contract governs final determination

Coverage determinations are made case‑by‑case and are subject to the member's contract and medical necessity requirements; the policy criteria provide guidance but the contract language prevails.

Final benefit determinations follow the applicable contract language and CMS NCDs/LCDs as applicable.

Step Therapy

Conservative therapy and monitored trial requirement (1–2 months)

For chronic non‑low‑back pain, other appropriate treatment modalities must have been tried and failed and a monitored trial rental of the TENS unit for a minimum of 30 days (up to 60 days) is required before purchase or continued coverage.

Trial period will be paid as a rental and must be monitored by the treating practitioner to determine effectiveness.
Purchase requires the treating practitioner to determine the member is likely to derive significant long‑term therapeutic benefit.

Note

See source for details.

Note

See source for details.

Note

See source for details.

Documentation Required

Document trial monitoring and lead‑configuration rationale; supplies require covered TENS

The medical record must document monitoring of the trial period effectiveness; if a 4‑lead unit is ordered for use with four leads, document why two leads are insufficient to meet the member's needs. Reimbursement for supplies is contingent on use with a covered TENS unit.

Treating practitioner must monitor trial effectiveness during the 30–60 day rental.
Document clinical rationale for 4‑lead versus 2‑lead configuration in the record.
Claims for supplies provided without a covered TENS unit will be denied.

Documentation Required

Documentation required to justify conductive garment (E0731)

To justify a conductive garment (E0731), the prescribing practitioner must state that the garment is prescribed for delivering covered TENS and document one of the listed medical indications (large/multiple stimulation sites, inaccessible sites to conventional electrodes, pre‑existing skin problems, or need to stimulate beneath a cast).

A conductive garment is rarely reasonable and necessary and is not covered during the trial period unless there is a documented pre‑existing skin problem and TENS is reasonable and necessary.

Documentation Required

Diagnosis linkage required for TENS (CLBP) — use Group 1 ICD‑10 codes

When billing TENS for chronic low back pain (E0720, E0730), documentation must support one of the Group 1 ICD‑10 diagnoses enumerated in the policy to establish medical necessity.

ICD‑10 codes not listed in the Group 1 support list do not support medical necessity for CLBP.

Documentation Required

Face‑to‑face exam required within 6 months; documentation must be received prior to delivery

The treating practitioner must have conducted a face‑to‑face examination within the six months preceding the written order as required by ACA 6407; documentation describing the medical condition for which DME is prescribed must be received prior to delivery.

This face‑to‑face exam requirement applies to items subject to ACA 6407 and documentation must be on file prior to delivery.
Providers/suppliers should not submit CMNs or DIFs with claims for dates of service on or after 2023-01-01.

Documentation Required

Face‑to‑face exam and CMN submission policy (ACA 6407)

Treating practitioner must have conducted a face‑to‑face exam within six months before the written order per ACA 6407; CMNs are no longer required for services on/after 2023‑01‑01 and should not be submitted with claims for those dates of service.

Documentation must describe the medical condition for which the DME is prescribed and be received prior to delivery.

Denial Risk

Denial risk — acute non‑postoperative pain (<3 months)

TENS will be denied as not reasonable and necessary for acute pain of less than three months' duration except when used for post‑operative pain.

Ensure documented indication is post‑operative if treatment is for acute pain less than three months to avoid denial.

Denial Risk

Denial risk — chronic pain or CLBP not meeting criteria

TENS therapy for chronic pain or CLBP that does not meet the policy criteria (duration, failed conservative therapies, or required diagnosis list) will be denied as not reasonable and necessary.

For chronic non‑CLBP, confirm pain ≥3 months and failed conservative modalities plus monitored trial.
For CLBP, confirm a Group 1 ICD‑10 diagnosis from the policy list.

Denial Risk

Denial risk — supplies billed without a covered TENS unit

Reimbursement for supplies will be denied when supplies are provided but no covered TENS unit is present.

Always bill supplies (A4557, A4595) only in association with a covered TENS device to avoid supply denials.

Denial Risk

Noncovered experimental HCPCS — K1016

Use of HCPCS code K1016 (transcutaneous electrical nerve stimulator for trigeminal nerve) and its monthly supplies is considered experimental/investigational and noncovered and may trigger claim denial.

Avoid using K1016 and related monthly supply codes for covered benefits; these are designated noncovered.

Denial Risk

Denial risk — unsupported diagnosis codes

ICD‑10 diagnosis codes not specified in the policy's Group 1 list do not support medical necessity for CLBP (and other unspecified codes do not support other TENS uses).

When billing E0720/E0730 for CLBP, include one of the Group 1 ICD‑10 codes from the policy to support coverage.

Billing Rule

Claim rejection risk when CMNs/DIFs are attached for DOS ≥ 2023‑01‑01

Claims with dates of service on or after January 1, 2023 will be rejected if CMNs or DIFs are attached; for dates prior to 2023‑01‑01, submit CMN/DIF with the claim if required or ensure it is on file.

Electronic filing requirements will cause claims with attached CMNs/DIFs on/after 2023‑01‑01 to be returned to the provider or supplier.

When CLBP criteria are met, conservative‑therapy trial is not required; for other TENS uses, diagnosis codes are not enumerated in policy.

Proportional billing guidance

If unit use is less than daily, frequency of billing for the supply code should be reduced proportionally

inv-58: Monthly billing cadence for supplies (A4595)

Supply code cadenceA4595 is billed per month (electrical stimulator supplies, 2-lead, per month)

Associated supply codeA4557 used for lead wires (per pair) with typical replacement interval guidance

Billing adjustmentReduce monthly billing frequency proportionally if the TENS unit is used less than daily

Coding implicationDifferent device classes may have distinct HCPCS/coding and coverage considerations

inv-49: TENS (E0720, E0730) — billing codes for CLBP

Billing codesE0720 and E0730 are the HCPCS device codes referenced for TENS use in chronic low back pain when policy requirements are met

Group 1 associationGroup 1 paragraph links E0720/E0730 use to the Group 1 ICD-10 diagnosis list for CLBP support

Coverage conditionalUse of these codes for CLBP requires meeting the policy's documented requirements and diagnosis linkage

inv-50: Group 2 — other uses of TENS

Uses includedGroup 2 covers other uses of TENS such as acute post-operative pain and chronic pain other than CLBP (no specified diagnosis codes)

No Group 2 ICDsPolicy states there are no specified diagnosis codes for Group 2 uses (Group 2: N/A)

Coverage rules differCoverage rules (e.g., trial rental, limitations) for Group 2 uses are set out separately from CLBP criteria

inv-51: Durable Medical Equipment (DMEPOS) — definition and coverage notes

Definition of DMEPOSDurable Medical Equipment is equipment used primarily and customarily for a medical purpose; items used primarily for non-medical purposes are not considered DME

Coverage caveatA finding that a DMEPOS product is reasonable and necessary does not itself constitute coverage; member contract terms prevail

Exclusions notedCertain devices (e.g., E0766 NOVOTTF) and other specified HCPCS have been identified as experimental/not covered

2016-10-21policy_change

Removed language requiring enrollment in a clinical study for CLBP diagnosis.

2016-12-08annual_review

Annual review recorded with no changes.

2017-12-20annual_review

Annual review with addition of Medicare ICD-10 codes M48.061 and M48.062.

2018-12-04annual_review

Annual review with updates to Medicare references.

2019-12-06annual_review

Annual review recorded with no changes.

2020-12-04annual_review

Annual review with terminology update changing 'physician' to 'treating practitioner'.

2021-12-14annual_review

Annual review removing references to CLBP clinical trials, removed QO modifier, and added NCD/LCD verbiage to the Important Note.

2022-09-13update

Added HCPCS codes K1016 and K1017 and designated them as experimental and investigational.

2022-12-02annual_review

Annual review updating policy per CMS CMN change effective 2023-01-01 (Certificate of Medical Necessity requirements updated).

2023-12-11annual_review

Annual review recorded with no clinical changes.

2024-12-05annual_review

Annual review with updated references (next review date noted 2024-02-05).

2025-12-10annual_reviewLatest

Annual review adding an Aetna CPB 0011 reference per the history entry.