Pneumatic Compression Device

Policy ID: Adm 134

Effective Date: January 01, 2027

Last Reviewed: June 12, 2026

Applies To: Migrated Commercial

This policy applies to all physicians, other health care professionals, hospitals and other facilities.

Definitions

Code/Term

Code Description/Term Definition

Durable Medical Equipment (DME)

DME is equipment that:

Can withstand repeated use;
Is primarily and customarily used to serve a medical purpose;
Generally, is not useful to a person in the absence of an illness or injury; and
Is appropriate for use in the home

All requirements of the definition must be met before an item can be considered durable medical equipment.

Pneumatic Compression Device (PCD)

Is durable medical equipment; A PCD is an electric or battery powered pump with attached inflatable appliances (sleeves) that fills with compressed air. As the appliance inflates, it applies compressive pressure gradient against the limb. The appliance is intermittently inflated and deflated to enhance the acceleration of blood flow through the limb.

Policy Statement

Our health plan requires the use of the following PCD/appliance Healthcare Common Procedure Coding System (HCPCS) code combinations:

E0650: Pneumatic Compressor, Non-Segmental Home Model (For lymphedema or chronic venous insufficiency). Segmental gradient pressure pneumatic appliances (E0671, E0672, E0673) are appliances/sleeves which are used with non-segmented pneumatic compressor (E0650), but which achieve a pressure gradient through the design of the tubing and/or air chambers.

E0655: Non-Segmental; Half Arm
E0660: Non-Segmental; Full Leg
E0665: Non-Segmental; Full Arm
E0666: Non-Segmental; Half Leg
E0671: Segmental; Full Leg
E0672: Segmental; Full Arm
E0673: Segmental; Half Leg

E0651: Pneumatic Compressor, Segmental Home Model without Calibrated Gradient Pressure (For lymphedema or chronic venous insufficiency)

E0667: Segmental; Full Leg
E0668: Segmental; Full Arm
E0669: Segmental; Half Leg

E0652: Pneumatic Compressor, Segmental Home Model with Calibrated Gradient Pressure (For lymphedema or chronic venous insufficiency)

E0656: Segmental; Trunk
E0657: Segmental; Chest
E0667: Segmental; Full Leg
E0668: Segmental; Full Arm
E0669: Segmental; Half Leg
E0670: Segmental; Two Full Legs and Trunk
E0671: Segmental; Full Leg
E0672: Segmental; Full Arm
E0673: Segmental; Half Leg

E0675: Pneumatic Compression Device, High Pressure, Rapid Inflation/Deflation Cycle, for Arterial Insufficiency (Unilateral or Bilateral System) (For Peripheral Artery Disease [PAD])

E0667: Segmental; Full Leg
E0668: Segmental; Full Arm
E0669: Segmental; Half Leg
E0676: Intermittent Leg Compression Device (Includes all Accessories), Not Otherwise Specified (For Deep Vein Thrombosis [DVT] Prevention)

Appliances/sleeves are included and not separately payable.

Postsurgical home use of an intermittent PCD for the purpose of prevention of venous thrombosis (E0676) is not eligible for reimbursement.

When a PCD is determined to be ineligible for reimbursement, all related appliances and accessories are also ineligible for reimbursement.

NOTE: Use of a PCD in a facility (i.e., Ambulatory Surgery Center [ASC]) is not eligible for reimbursement as it is included in the facility fee for the procedure(s); as such not separately allowable when billed by the facility or a DME supplier, or other provider.

References

Center for Medicare & Medicaid Services (CMS), HCPCS Level II codes

Cross References

Adm 107 - Non-Reimbursable Services

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

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