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26.2.10.1 NMES and TENS Garments
The prior authorization request form for the purchase of the NMES and TENS conductive garments must include supporting documentation that shows:
• The garment has been prescribed by a physician for use in delivering covered NMES and TENS treatment.
•The client has successfully completed a 1-month trial period.
•The conductive garment is necessary for one of the medical indications outlined below:
•The client 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.
•The client 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.
•The client has a documented medical condition, such as a skin problem, that precludes the application of conventional electrodes, adhesive tapes, and lead wires.
The rental of the NMES and TENS garment is not a benefit during the trial rental period unless the client has a documented skin problem prior to the start of the trial period; and the Department of State Health Services (DSHS) or its designee is satisfied that the use of such an item is medically necessary for the client.
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