TRICARE Coverage had changed recently: here is what you need to know
The TRICARE Healthcare coverage program serves active duty and retired service members. It also covers their families world-wide. Like every other insurance plan, it has coverage determinations that include and disallow treatments. While many insurances implement changes at the turn of the calendar year, we can see alterations at other times. Generally, changes are announced with a time frame attached in order to allow plan participants and provides a chance to be alerted and plan accordingly. However, there can be alterations in plans that take place immediately.
Recently the TRICARE Health program announced they will disallow transcutaneous electrical nerve stimulation (TENS) as a reimbursable treatment for low back pain. The TENS decision was announced by the Defense Health Agency on February 26th and is effective June 1, 2020. In the notice of the change, the DoD says the TRICARE policy manual will now list TENS as an “unproven” treatment for low back pain and therefore is not eligible for coverage. Up until this point TRICARE contractors were allowed to decide whether TENS was medically necessary for treatment of low back pain.
They announced “After years of not issuing guidance on the use of transcutaneous electrical nerve stimulation (TENS) to treat lower back pain, Tricare is officially excluding the machines from coverage, effective June 1.” According to a recent article in Military.com, DoD arrived at its decision after reviewing multiple studies that found weak evidence for the effectiveness of TENS for LBP, with a TRICARE official telling the site that the findings indicated that “TENS for lower back pain is no more effective than … placebo.”1
Tricare officials said they decided to stop letting the Tricare contractors decide whether TENS was medically necessary after studies by the American College of Physicians, along with the Defense Department and Department of Veterans Affairs, found “insufficient evidence” that the treatment is effective in treating acute, subacute and chronic lower-back pain. “Additionally, reliable evidence in published medical literature increasingly finds that TENS for lower back pain is no more effective than sham TENS (placebo),” a Tricare official said via email.
TENS is electrical stimulation to nerves, muscles and tendons to relieve pain. It can be administered in a clinic or at home with a prescribed machine. Several patients in one 2011 study experienced skin irritation, one to the point of dropping out.2 Tricare contractors Humana Military and Health Net Federal Services currently must decide whether to cover an item not specifically mentioned in the Tricare manual, like TENS was. The decision to cover is made after the contractors prove it to be safe and effective, medically necessary, and appropriate, the Tricare official said.
“Physical therapy visits where the only treatment provided is TENS for lower back pain are not eligible for cost sharing,” the Tricare official added. “TENS therapy delivered during an otherwise covered physical therapy visit would also be ineligible for cost sharing. “The exclusion from coverage later this year will affect both TENS treatments at home and those directly provided at a clinic.
In another recent announcement the DoD agency that oversees TRICARE reports that dry needling will not be covered if it’s the sole purpose for a visit. The revised TRICARE policy manual also lists dry needling as an “unproven” treatment. This change is not only for lower back pain, but for any condition. The change means that TRICARE will not cover a physical therapy visit if dry needling is the “sole purpose” for the session. This policy is effective immediately. When asked to comment the American Physical Therapy Association stated “The APTA is disappointed in the Defense Health Agency’s decision and questions some of the evidence used to support its decision, and that this doesn’t change our commitment to advocating for coverage for these services across payers,” said Kara Gainer, APTA’s director of regulatory affairs. “Patient access to the most appropriate, evidence-based care and respect for the clinical decision-making skills of physical therapists remain at the heart of our policy efforts.”