Transcutaneous electrical nerve stimulators (TENS) units are considered medically necessary durable medical equipment (DME) when used as an adjunct or as an alternative to the use of drugs either in the following situations:
· An adjunct in the treatment of acute post-operative pain in the first 30 days after surgery.
· An adjunct in the treatment of certain types of chronic, intractable pain not adequately responsive to other methods of treatment, as appropriate, physical therapy and pharmacotherapy.
When the TENS unit is used for the acute post-operative or chronic intractable pain, ConnectCare considers use of the device medically necessary for a trial period of 1 month. Physician records must document a reevaluation of the member at the end of the trial period, indicating how often it was used, the duration of use and its effectiveness. Continued TENS treatment may be considered medically necessary if the treatment significantly alleviates pain and the physician documents the patient is likely to derive benefit from its continued long term use.
Follow Up TENS/Neuromuscular Stimulator
Progress Evaluation Report
Name of Therapist: _______________________________________
Patient Name: ___________________________________________
Date of Initial Evaluation: _______________
Date of Re-Evaluation:__________________
Date Patient was Last Seen: ______________
Patient has been receiving the following results from the use of a ___________________
___ Fair ___Moderate ___Excellent
Has this patient had increased functions in his/her daily activities and work functions?
___Yes ___No
If Yes, which functions have increased? __________________________________
__________________________________________________________________
__________________________________________________________________
On what area of the body is the unit being used? ________________________________
How often in a 24-hour period is the unit being used? _____hrs per day / _____ per week
Patient’s activity / movements have; _____improved greatly_____improved moderately
_____improved slightly_____stayed the same
On a scale of one (no pain) to ten (severe pain), the patient’s current pain level is: _____
Before using the prescribe modality, the pain level was: _____
Briefly describe the patient’s plan of treatment with the prescribed modality: _________
______________________________________________________________________
Please indicate the period of necessity: _____ 6 months
_____ 9 months
_____ 1 year or more
I recommend the unit be purchased for continued usage, it is my professional opinion that the patient is benefiting from this modality.
__________________________________ ________________
Therapist Signature
