Tip sheet/download
4
min
read

Deciphering durable medical equipment

This guide clarifies the use of various devices where there is often confusion
Back to Knowledge Center

This guide clarifies the use of various devices where there is often confusion or inappropriate prescribing. 

Prior authorization is not required if the use of particular types of durable medical equipment (DME) is consistent with the Division of Workers’ Compensation (DOWC) Medical Treatment Guidelines (MTG). However, DME use in the absence of prior authorization may be subject to retrospective audit and review for medical reasonableness and necessity, which, in certain instances, can result in denial of payment. 

In all cases, an injured worker should be monitored by the treating provider to ensure device effectiveness. To justify continued use, the treating provider must verify and document that the injured worker is deriving meaningful therapeutic benefit. 

TENS and NMES 

Transcutaneous Electrical Nerve Stimulator (TENS) and Neuromuscular Electrical Stimulation (NMES) devices are often confused with each other, but they are different devices with different clinical indications. 

TENS provides electrical stimulation of peripheral nerves for the treatment of acute postoperative pain and certain chronic, intractable pain conditions. According to the MTG, the optimal number of sessions for lower extremity, shoulder and back injuries is three. TENS should include at least one instructional session in the clinic prior to home use. Consistent and measurable functional improvement must be documented prior to the purchase of a home unit. 

NMES involves the application of electrical current to atrophied or paralyzed muscles to improve their function by means of eliciting involuntary or assisted contractions. NMES, also known as “functional electrical stimulation” in the MTG, is often confused with TENS and ordered in error. It is rarely indicated and is often used inappropriately. The MTG indicate the optimal duration is eight weeks. A 30-day trial rental with documented effectiveness (improved function, decreased pain) is required prior to purchase. 

Continuous Passive Motion (CPM) 

CPM involves the use of specialized equipment to passively move joints, most commonly knees and hips after surgery. However, indications for CPM in the MTG are very limited. The potential use of CPM is warranted only for postoperative knee microfracture, autologous cartilage implantation, and postoperatively for hip microfracture. 

CPM is not recommended for total knee arthroscopy (TKA). When compared with standard physical therapy or home exercises, CPM has no beneficial effects on short-term TKA outcomes of range of motion, pain and hospital stay nor on medium-term outcomes related to function and quality of life. 

CPM is not recommended by itself or as an adjunct to standard physical therapy for most shoulder injuries, including after arthroscopic rotator cuff surgery. 

Cold therapies 

Passive circulating cold and cold-pack therapy are used to reduce tissue temperature for the reduction of injury-associated pain, edema, inflammation and effusion. The MTG recommend these devices for a variety of clinical indications, and the optimal duration of use is three to four weeks.

Active cold units combine cold with intermittent vasopneumatic compression and are intended for lymphedema that is unresponsive to other therapies, for DVT, and for chronic venous insufficiency with ulceration and complications. 

The MTG do not provide evidence of improved clinical outcome with use of vasopneumatic devices for other conditions, and inappropriate use may result in skin blistering, burning, itching or pain. 

For payer approval, authorization requests require documentation of medical necessity to manage systemic conditions based on a diagnosis such as peripheral arterial disease or venous thrombosis. 

Vasopneumatic devices are often ordered when mechanical compression is not clinically indicated.

This information is not intended in any way to dictate the type or duration of medical treatment that may be prescribed. Providers must exercise independent medical judgment in prescribing treatment.  

If you have questions, please contact us at billingsuccess@pinnacol.com.

View
PDF
COVID-19 Policy Update