Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic lymphedema, venous insufficiency, and morbid obesity

Treatment: Pneumatic compression device system (Flexitouch) for date of service specified:  E0652- pneumatic compression of the lower extremities with Calibration; and E0667- above the knee compression appliances. 

The insurer denied coverage for pneumatic compression device system (Flexitouch) for date of service specified:  E0652- pneumatic compression of the lower extremities with Calibration; and E0667- above the knee compression appliances. The denial was reversed.

This patient is a male currently diagnosed with lymphedema, venous insufficiency morbid obesity.  The progress note from a specified date indicated that the patient was seen for a follow-up visit.  The patient's ulcer was improved.  Leg, ankle and foot circumferences were obtained to assess changes and edema/fluid status.  The main problem was lymphedema and uncontrolled swelling of the legs in order to improve the edema as well as ulcers that the patient would benefit from Flexitouch lymphedema pump as other methods of conservative therapy had been exhausted.  The patient was to continue with compression to maintain control of the patient's edema.  It was noted the patient would benefit from adding a lymphedema pump to the regimen.  The appeal letter noted that since the patient received the pump, the patient had been using the pump as prescribed.  The patient noted improvement in mobility and reduction in swelling since starting the treatment.  Prior to using the pump, the patient rated his lymphedema and swelling as a 9/10.  Now it was rated at a 5/10.  The patient's spouse noticed improvement after use. Previous treatment failed to effectively control symptoms including lymphedema home therapy with bandaging, garments, exercise and elevation for at least four weeks. 

 The standard of care for lower extremity lymphedema is multimodal therapy, which is aimed at improving patient comfort and reducing limb volume, since the underlying disease cause cannot usually be corrected.  Conservative/multimodal therapy consists of general measures for self-care such as monitoring, limb elevation, skin care, weight reduction with diet and exercise, and compression therapy such as compression bandaging, compression garments, and intermittent pneumatic compression as well as physiotherapy.  A segmented device with calibrated gradient pressure (E0652) is characterized by a manual control on at least three outflow ports, which can deliver an individually determined pressure to each segmental unit. For this patient, the clinical information submitted shows the patient has a diagnosis of lymphedema to the bilateral lower extremities.  The patient had tried and failed home lymphedema therapy including bandaging, garments, exercise, and elevation for at least 4 weeks without benefit.  Basic pneumatic compression devices were ruled out due to risk of causing trunk/chest/abdominal swelling, open wounds/ulcers/skin breakdown which preclude use of static pressures applied by a basic pump.  

The requested Flexitouch pneumatic compression device system would be the most appropriate treatment for the patient.  As such, the requested pneumatic compression device system (Flexitouch) for date of service specified E0652, E0667 would be medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the pneumatic compression device system (Flexitouch) for date of service specified: E0652- pneumatic compression of the lower extremities with Calibration; and E0667- above the knee compression appliances is reversed.  The medical necessity is substantiated.