A pneumatic compression therapy device functions as a pump to improve circulation. The device consists of an inflatable garment, usually for the arm, leg, and/or ankle, and an electric pump. The inflatable garment is intermittently inflated and deflated in a cycle of time and pressure. Pneumatic compression therapy devices are classified as non-segmented or segmented, with or without calibrated gradient pressure.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Coverage is subject to the specific terms of the member's benefit plan.
Pneumatic compression devices/lymphedema pumps and appliances may be covered as durable medical equipment (DME) when ALL of the following are met:
Segmented or non-segmented pneumatic compression devices without calibrated gradient pressure for home use may be considered medically necessary for the treatment of ANY ONE of the following:
In-home use of limb compression devices for the following indications may be considered medically necessary for ANY ONE of the following:
In-home use of limb compression devices for VTE prophylaxis for the following conditions, are considered experimental/investigational and, therefore, non-covered:
The efficacy of these devices for the above conditions is unproven.
A portable, intermittent, limb compression device (i.e. Vena Pro) is considered experimental/ investigational and, therefore, non-covered. There is a lack of evidence based literature to confirm the efficacy and safety of these devices.
In-home use of limb compression devices for VTE prophylaxis for periods longer than 30 days post-surgery is not medically necessary.
Segmented pneumatic compression therapy devices with calibrated gradient pressure may be considered medically necessary when the following medical necessity criteria are met:
Segmented pneumatic compression therapy devices with calibrated gradient pressure not meeting the above criteria are considered not medically necessary.
The use of pneumatic compression devices for the treatment for lymphedema of the chest or trunk, and for the treatment of arterial insufficiency, is considered experimental/investigational and, therefore, non-covered. The evidence is insufficient to determine the effects of the technology on health outcomes.
Guidance on Determining High Risk for Bleeding
American College of Chest Physicians (ACCP) 2012 guidelines on prevention of VTE in orthopedic surgery patients list the following general risk factors for bleeding:
The guidelines note, however, that specific thresholds for using mechanical compression devices or no prophylaxis instead of anticoagulant thromboprophylaxis have not been established.
Guidance on Risk Level for Patients Undergoing Non-orthopedic Surgery
The 2012 ACCP guidelines on prevention of VTE in non-orthopedic surgery patients included the following discussion of risk levels: "In patients undergoing general and abdominal-pelvic surgery, the risk of VTE varies depending on both patient-specific and procedure-specific factors. Examples of relatively low-risk procedures include laparoscopic cholecystectomy, appendectomy, transurethral prostatectomy, inguinal herniorrhaphy, and unilateral or bilateral mastectomy. Open abdominal and open-pelvic procedures are associated with a higher risk of VTE. VTE risk appears to be highest for patients undergoing abdominal or pelvic surgery for cancer..."
"Independent risk factors include age at least 60 years, prior VTE, and cancer; age >60 years, prior VTE, anesthesia at least 2 hours, and bed rest at least 4 days; older age, male sex, longer length of hospital stay, and higher Charlson comorbidity score; and sepsis, pregnancy or postpartum state, central venous access, malignancy, prior VTE, and inpatient hospital stay more than 2 days. In another study, most of the moderate to strong independent risk factors for VTE were surgical complications, including urinary tract infection, acute renal insufficiency, postoperative transfusion, perioperative myocardial infarction, and pneumonia".
The American College of Obstetricians and Gynecologists (ACOG 2007, 2012) proposed the following risk classification for VTE in patients undergoing major gynecological surgery:
COVERED DIAGNOSIS CODES FOR PROCEDURE CODES; E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0671, E0672, E0673