Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema

Treatment: E0652, pneumatic compressor, segmental home model with calibrated gradient pressure, E0565, segmental pneumatic appliance for use with pneumatic compressor, trunk, and E0667, segmental pneumatic appliance for use with pneumatic compressor, full leg

The insurer denied coverage for E0652, pneumatic compressor, segmental home model with calibrated gradient pressure, E0565, segmental pneumatic appliance for use with pneumatic compressor, trunk, and E0667, segmental pneumatic appliance for use with pneumatic compressor, full leg,

The denial is upheld

This case involves a female with a subject of review for pneumatic compression, segmental home model with calibrated gradient pressure, segmental pneumatic appliance for use with the device, trunk and full leg. The patient was seen for an evaluation to rule out varicose vein disease. The patient reported that her symptoms worsened with or after activity. She had worn gradient compression stockings for at least 6 months. The review of systems was positive for edema, heaviness, leg aching, leg pain, and swelling. The symptoms affected the patient's activities of daily living. The exam findings of the patient noted normal pulses in the bilateral lower extremities. Her diagnoses included venous insufficiency, leg swelling, and hereditary lymphedema.  There was no evidence of venous insufficiency. It was unlikely that the patient was developing lymphedema or lipedema. An endocrine evaluation was recommended to rule out endocrine/hormonal causes of leg swelling.

Per the plan policy, segmented pneumatic compression devices may be indicated for the treatment of lymphedema when simpler pumps are not effective. The plan requires a 4-week trial of basic pumps. Per the cited additional sources, intermittent pneumatic compression with extremity pump is recommended for lymphedema when the patient is participating in complete decongestive therapy program. The documentation should identify discomfort, heaviness, pain, recurrent skin infections, or reduced function.  The documentation should identify that the patient is unable to perform other compression intervention, or failure of other compression intervention to relieve symptoms after 4 more weeks of treatment. In this case, the patient was diagnosed with lymphedema. The provider stated that the patient was unable to utilize basic pumps as there was a risk of causing proximal/truncal swelling. However, while the prescription reported truncal swelling, the exam findings did not report truncal swelling. Given that the treating provider found a diagnosis of lymphedema questionable, and the documentation did not reveal exam findings consistent with truncal swelling, a trial of basic pumps would be appropriate for this patient prior to consideration for segmental pneumatic devices based on the plan policy and medical necessity. As such, the denial of coverage for E0652, pneumatic compressor, segmental home model with calibrated gradient pressure, E0565, segmental pneumatic appliance for use with pneumatic compressor, trunk, and E0667, segmental pneumatic appliance for use with pneumatic compressor, full leg, was appropriate and is upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the E0652, pneumatic compressor, segmental home model with calibrated gradient pressure, E0565, segmental pneumatic appliance for use with pneumatic compressor, trunk, and E0667, segmental pneumatic appliance for use with pneumatic compressor, full leg is upheld. Medical Necessity is not substantiated.