Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Compression devices to treat only for edema, venous insufficiency, and lymphedema are covered subject to a determination of medical necessity. In general, these devices will be covered without preauthorization under the member’s DME benefit. However, devices with calibrated gradients of pressure require pre-authorization, and are also covered under the member’s DME benefit.  Pumps and pads with circulation of hot or cold water are not covered. Please also see BI024 regarding medical necessity.

The following codes for pumps and pads with circulation of hot or cold water are not covered: E0675 – E0676, E0217, E0218, E0236, and E0249.

1)    Lymphedema

a)    Pneumatic compression devices are covered in the home setting for the treatment of lymphedema if the patient has undergone a four-week trial of conservative therapy and there has been no significant improvement or significant symptoms remain after the trial.

b)    The trial of conservative therapy must include:

i)     Use of an appropriate compression bandage system or compression garment (The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.); AND

ii)    Exercise, AND

iii)   Elevation of the limb.

c)    Requests for pneumatic compression with calibrated gradients of pressure (E0652) require first trying conservative therapy AND conventional (non-calibrated) pneumatic compression devices without significant improvement.

d)    For use of pneumatic compression devices in the office, see BI227.

2)    Chronic Venous Insufficiency with Venous Stasis Ulcers (CVI)

a)    Pneumatic compression devices are covered in the home setting for the treatment of CVI of the lower extremities only if the patient has one or more venous stasis ulcer(s) which have failed to heal after a 6 month trial of conservative therapy.

b)    The trial of conservative therapy must include:

i)     A compression bandage system or compression garment (see above); AND

ii)    Appropriate dressings for the wound; AND

iii)   Exercise; AND

iv)   Elevation of the limb.

c)    Requests for pneumatic compression with calibrated gradients of pressure (E0652) require first trying conservative therapy AND conventional (non-calibrated) pneumatic compression devices without significant improvement.

3)    Intermittent Pneumatic Compression Devices

a)    Intermittent pneumatic devices are covered for home use to stimulate circulation and reduce the chances of deep venous thrombosis for members who have no or limited ability to walk.

b)    Due to trauma, orthopedic surgery, neurosurgery or other circumstances preventing or impairing ambulation.

Codes Used In This BI:

E0217            Water circulating heat pad with pump

E0218            Fluid circulating cold pad with pump, any type (code revised 1/1/19)

E0236            Pump for water circulating pad

E0249            Pad for water circulating heat unit, replacement

E0650            Pneumatic compressor, Nonsegmental home model

E0651            Pneumatic compressor, segmental home model w/out calibrated gradient pressure

E0652            Pneumatic compressor, segmental home model w/calibrated gradient pressure

E0655            Nonsegmental pneumatic appliance for use w/pneumatic compressor, half arm

E0656            Segmental pneumatic appliance for use w/pneumatic compressor, trunk

E0657            Segmental pneumatic appliance for use w/pneumatic compressor, chest

E0660            Nonsegmental pneumatic appliance for use w/pneumatic compressor, full leg

E0665            Nonsegmental pneumatic appliance for use w/pneumatic compressor, full arm

E0666            Nonsegmental pneumatic appliance for use w/pneumatic compressor, half leg

E0667            Segmental pneumatic appliance for use w/pneumatic compressor, full leg

E0668            Segmental pneumatic appliance for use w/pneumatic compressor, full arm

E0669            Segmental pneumatic appliance for use w/pneumatic compressor, half leg

E0671            Segmental gradient pressure pneumatic appliance, full leg

E0672            Segmental gradient pressure pneumatic appliance, full arm

E0673            Segmental gradient pressure pneumatic appliance, half leg

E0675            Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)

E0676            Intermittent limb compression device (incl all accessories), not otherwise specified

Pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patient`s condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment.

2.    A non-segmented device or segmented device without manual control of the pressure in each chamber is generally considered sufficient.

3.    A segmented, calibrated gradient pneumatic compression device would be covered when it is documented that the patient is not receiving satisfactory pneumatic compression treatment using a conventional, non-calibrated device.

4.    A 10 chamber device will be covered only when there is significant documentation that a 6 chamber device is ineffective

5.    Intermittent pneumatic compression boots are not covered for treatment of chronic venous stasis ulcers, peripheral arterial occlusive disease/arterial insufficiency, and all other indications because there is inadequate evidence of their effectiveness for these indications.

6.    Pumps and pads for circulating hot or cold water are not covered since they offer no advantage over hot/cold packs.

7.    Non-specific intermittent limb compression devices are not covered since more specific codes are available.

1.      Women`s Health and Cancer Rights Act of 1998. Pub. L. No. 105-277. October 21, 1998. Available at: http://www.hcfa.gov/medicaid/hipaa/content/whcra.pdf. Accessed August 6, 2001.

2.      ArmAssist Non-Elastic Adjustable Limb Containment System [website]. Tampa, FL: Trinity Lymphedema Centers; 2002.

3.      TriCenturion, LLC. Pneumatic compression devices (used for lymphedema). Policy No. LYPH20021201. Medicare Local Medical Review Policy. DMERC Region A. Columbia, SC: TriCenturion; April 1, 2002.

4.      Tiwari A, Cheng KS, Button M, et al. Differential diagnosis, investigation, and current treatment of lower limb lymphedema. Arch Surg. 2003; 138(2):152-161.

5.      International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology. Lymphology. 2003;36(2):84-91.

6.      Medicare National Coverage bulletin 60-16 at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=60-16&ncd_version=1&show=all

7.      Colwell C, et.al.  Mobile Compression Device for Thrombosis Prevention in Hip and Knee Arthroplasty. J Bone Joint Surg Am, 2014 Feb 05; 96(3): 177-183.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.