Diagnosis: Degenerative disc disease
Treatment: Code E0745 neuromuscular stimulator for shock
The insurer denied coverage for Code E0745 neuromuscular stimulator for shock.
The denial is overturned.

This is the case of a patient with a history of anxiety disorder, degenerative disc disease, neck and back pain. The patient's Physical Therapy (PT) note stated that the physical therapy treatment has focused on pain management, manual and mechanical joint decompression via cervical traction, the original 7/10 pain level had reduced in size; but the physician is recommending a transcutaneous electrical nerve stimulation (TENS) for pain relief. The patient's magnetic resonance imaging (MRI) lumbar reading stated multilevel small protrusions at lumbar (L) 2-3, L3-4 and L4-5.

The medical record documents criteria have been met:

The device is beneficial for people with chronic pain. There should be confirmation of duration, medications and a course of PT. There should be evidence of TENS usage for at least one month.

These facts have been confirmed. As benefit was noted, a home unit would be beneficial and should be provided.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Code E0745 neuromuscular stimulator for shock, is substantiated.