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Pneumatic Compression Devices

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: July 16, 2019

Description

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. 

Criteria

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: 

  • When prescribed by a physician; and
  • Has appropriate physician oversight (i.e., physician evaluation of the patient's condition to determine medical necessity of the device, suitable instruction in the operation of the machine as to the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment). 

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: 

  • Lymphedema treatment (pumps and appliances) of the arm or leg that has failed a four (4) week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include ALL of the following: 
    • A compression bandage system or compression garment; and
    • Appropriate dressings for the wound; and
    • Exercise; and
    • Elevation of the limb. 

OR

  • Chronic venous insufficiency (CVI) of the lower extremities with non-healing venous stasis ulcer(s) after a six (6) month trial of conservative therapy directed by the treating physician. The trial of conservative therapy must include ALL of the following: 
    • A compression bandage system or compression garment; and
    • Appropriate dressings for the wound; and
    • Exercise; and
    • Elevation of the limb. 

OR

In-home use of limb compression devices for the following indications may be considered medically necessary for ANY ONE of the following: 

  • Prevention of post-thrombotic syndrome; or
  • Venous thromboembolism (VTE) prophylaxis after major orthopedic surgery (e.g. total hip arthroplasty, total knee arthroplasty, hip fracture surgery) in patients with a contraindication to pharmacological agents, i.e., at high risk for bleeding; or
  • VTE prophylaxis after major non-orthopedic surgery or non-major orthopedic surgery in patients who are at moderate or high risk of VTE (see Professional Statements and Societal Positions) with a contraindication to pharmacological agents, i.e., at high risk for bleeding. 

In-home use of limb compression devices for VTE prophylaxis for the following conditions, are considered experimental/investigational and, therefore, non-covered: 

  • After major orthopedic surgery for individuals without a contraindication to pharmacological prophylaxis; or
  • After major non-orthopedic surgery or non-major orthopedic surgery, for individuals who are at moderate or high risk of VTE without a contraindication to pharmacological prophylaxis and in patients who are at low risk of VTE; or
  • After all other surgeries. 

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. 

Procedure Codes 

E0650 E0651 E0652 E0655 E0660
E0665 E0666 E0667 E0668 E0669
E0671 E0672 E0673 E0676 E1399

Segmented pneumatic compression therapy devices with calibrated gradient pressure may be considered medically necessary when the following medical necessity criteria are met: 

  • The individual's medical condition has failed to respond to therapy using a segmented pneumatic compressor without calibrated gradient pressure with clear documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented device without manual control of the pressure in each chamber. 

Segmented pneumatic compression therapy devices with calibrated gradient pressure not meeting the above criteria are considered not medically necessary. 

Procedure Codes 

E0652 E0671 E0672 E0673

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. 

Procedure Codes

E0656 E0657 E0670 E0675 E1399

Professional Statements and Societal Positions 

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: 

  • Previous major bleeding (and previous bleeding risk similar to current risk) 
  • Severe renal failure 
  • Concomitant antiplatelet agent Surgical factors: history of or difficult-to-control surgical bleeding during the current operative procedure, extensive surgical dissection, and revision surgery 

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: 

  • Low: Surgery lasting less than 30 minutes in patients younger than 40 years with no additional risk factors. 
  • Moderate: Surgery lasting less than 30 minutes in patients with additional risk factors; surgery lasting less than 30 minutes in patients age 40 to 60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors. 
  • High: Surgery lasting less than 30 minutes in patients older than 60 years or with additional risk factors; major surgery in patients older than 40 years or with additional risk factors. 
  • Highest: Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state.

Diagnosis Codes

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES; E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0671, E0672, E0673

I87.2  I87.011  I87.012  I87.013  I87.021  I87.022  I87.023 
I87.031  I87.032  I87.033  I87.091  I87.092  I87.093  I87.2 
I89.0  I97.2  L97.111  L97.112  L97.113  L97.114  L97.115 
L97.116  L97.118  L97.119  L97.121  L97.122  L97.123  L97.124 
L97.125  L97.126  L97.128  L97.129  L97.211  L97.212  L97.213 
L97.214  L97.215  L97.216  L97.218  L97.219  L97.221  L97.222 
L97.223  L97.224  L97.225  L97.226  L97.228  L97.229  L97.311 
L97.312  L97.313  L97.314  L97.315  L97.316  L97.318  L97.319 
L97.321  L97.322  L97.323  L97.324  L97.325  L97.326  L97.328 
L97.329  L97.411  L97.412  L97.413  L97.414  L97.415  L97.416 
L97.418  L97.419  L97.421  L97.422  L97.423  L97.424  L97.425 
L97.426  L97.428  L97.429  L97.505  L97.506  L97.508  L97.511 
L97.512  L97.513  L97.514  L97.515  L97.516  L97.518  L97.519 
L97.521  L97.522  L97.523  L97.524  L97.525  L97.526  L97.528 
L97.529  L97.811  L97.812  L97.813  L97.814  L97.815  L97.816 
L97.818  L97.819  L97.821  L97.822  L97.823  L97.824  L97.825 
L97.826  L97.828  L97.829  L97.911  L97.912  L97.913  L97.914 
L97.915  L97.916  L97.918  L97.919  L97.921  L97.922  L97.923 
L97.924  L97.925  L97.926  L97.928  L97.929  L98.415  L98.416 
L98.418  L98.425  L98.426  L98.428  L98.495  L98.496  L98.498 
Q82.0

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