CMS has issued an August 2012 memo to clarify a June 8, 2012 Centers for Medicare & Medicaid Services announcement which confirmed TENS Units would no longer be covered as a Medicare allowable expense for Chronic Low Back Pain (CLBP). The CMS Decision Memo defined CLBP as “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.”
The Decision Memo also stated that a TENS unit is not reasonable and necessary for the treatment of CLBP, in accordance with the provisions of section 1862(a)(1)(A) of the Social Security Act.
The recent change in coverage of TENS units for CLBP will have the following impacts upon the WCMSA proposal review process:
Effective June 8, 2012, for those workers’ compensation (WC) cases settled prior to June 8, 2012, and where the settlement included pricing for TENS for CLBP, CMS will consider funds spent for TENS for CLBP by beneficiaries and claimants as being an appropriate expenditure of funds as part of the WCMSA.
For those WC cases that were not settled prior to June 8, 2012, and where the WCMSAs proposal includes funding for TENS for CLBP as part of the WCMSA, CMS will re-review the cases and remove pricing for TENS for CLBP.
Regional Offices shall obtain from submitters requests for a case re-review, along with a signed statement indicating a settlement had not occurred prior to June 8, 2012. Once CMS performs a re-review of WCMSAs to remove pricing for TENs for CLBP, beneficiaries and claimants may not use funds from their WCMSA to pay for non-covered TENS Units for CLBP as this will now be deemed an inappropriate expenditure of WCMSA funds.
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If you would like a copy of the CMS memo mentioned above or have questions or concerns about such issues, please feel free to contact Shawn or Matt.