A form-fitting conductive garment (E0731)(and medically necessary related supplies) may be covered only when:

1. The garment has received permission or approval for marketing by the Food and Drug Administration;
   
   
2. The garment has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and
   
   
3. One of the medical indications outlined below is met:
   
   
   
   1. The patient 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;
      
      
   2. The patient 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;
      
      
   3. The patient has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires;
      
      
   4. The patient 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
      
      
   5. The patient 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.

1. The patient has a documented skin problem prior to the start of the trial period;
   
   
2. The medical review establishes that use of a conductive garment is medically necessary for the patient.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

For additional information, see Medical Policy Bulletins Y-7 (NMES) and Z-7 (TENS).

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

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

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

MCIM 45-25