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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules state that a Pneumatic Compression Device (PCD) coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met:1. The beneficiary has a diagnosis of lymphedema as defined above, and2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings:Marked hyperkeratosis with hyperplasia and hyperpigmentation,Papillomatosis cutis lymphostatica,Deformity of elephantiasis,Skin breakdown with persisting lymphorrhea,Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.)A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-week trial of conservative therapy must include all of the following:1. Regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compressionAdequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid movement, and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal to proximal. The compression used must not create a tourniquet effect at any point.The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression starting with a minimum of 30 mmHg distally.2. Regular exercise3. Elevation of the limbWhen available, manual lymphatic drainage is a key component of conservativetreatment as is appropriate medication treatment when there is concurrent congestive failure.At the end of the four-week trial, if there has been improvement, then reimbursement for a PCD is not justified. Where improvement has occurred, the trial of conservative therapy must be continued with subsequent reassessment at intervals at least a week apart. Only when no significant improvement has occurred in the most recent four weeks and the coverage criteria above are still met, may the lymphedema be considered unresponsive to conservative therapy, and coverage for a PCD considered.PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related accessories are not eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary.You can find these rules in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan coversitems and services in accordance with Medicare rules.