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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 say PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for the
treatment of chronic venous insufficiency with venous stasis ulcers. Reimbursement for these items is based
upon the criteria in the following sections. PCD coded as E0675 is used in the treatment of peripheral arterial
disease. Claims for E0675 will be denied as not reasonable and necessary as outlined below.
A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the
criteria in this section are met. Claims will be denied as not reasonable and necessary. Refer below to the
sections III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN and PCD
Code Selection for additional information about the limited coverage for PCD coded as E0652.
Four-Week Trial for Lymphedema
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:
Regular and compliant use of an appropriate compression bandage system or compression garment to
provide adequate graduated compression
Adequate 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.
Regular exercise
Elevation of the limb
When available, manual lymphatic drainage is a key component of conservative treatment 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.
The medical necessity determination for a PCD by the treating practitioner must include symptoms and
objective findings, including measurements, to establish the severity of the condition.
The documentation by the treating practitioner of the medical necessity of a pneumatic compression device
must include:
The patient's diagnosis and prognosis;
Symptoms and objective findings, including measurements which establish the severity of the condition;
The reason the device is required, including the treatments which have been tried and failed; and
The clinical response to an initial treatment with the device
At a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same
manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials
and therapy, with bilateral comparisons where appropriate.
The trial of conservative therapy must be documented in the beneficiary's medical record before prescribing
any type of pneumatic compression device (E0650, E0651, E0652). This assessment may be performed by the
treating practitioner or any other licensed/certified medical professional (LCMP) directly involved in the
beneficiary's lymphedema treatment. The LCMP may not have any financial relationship with the DMEPOS
supplier providing the device. If the assessment is performed by an LCMP, the treating practitioner must
receive and review the report of the evaluation. In addition, the treating practitioner must sign and date the
report, and state concurrence or disagreement with the assessment. The signature date must be on or before the
prescription date.
A segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) is only covered when
the individual has unique characteristics which prevent them from receiving adequate satisfactory pneumatic
compression treatment using a nonsegmented device along with a segmented appliance or compression device
without manual control of the pressure in each chamber.
A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or
abdomen when all of the following are met:
The beneficiary has lymphedema of an extremity as defined above
The coverage criteria for an E0650 or E0651 are met
The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve
with a four-week trial. (See below for trial guidelines.)
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable
and necessary.
A PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI
is not eligible for reimbursement. Claims will be denied as not reasonable and necessary.
Four-Week Trial for Lymphedema Extending Onto the Chest, Trunk and/or Abdomen
A four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651
is required. The four-week trial of conservative therapy must include all of the following:
At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, inperson
fitting, training and supervision by a technician who is skilled in and who regularly and successfull y
uses the appliance provided
Compliant use of an appropriate compression bandage system or compression garment to provide adequate
graduated compression
Adequate 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.
Regular exercise
Elevation where appropriate
Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30
minutes per day
Evaluation of diet and implementation of any necessary change
Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.)
Correction (where possible) of anemia and/or hypoprotenemia
At the end of the four-week trial, if there has been improvement of the lymphedema extending onto the chest,
trunk and/or abdomen, then reimbursement for an E0652 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.
When and only when no significant improvement has occurred in the most recent four weeks and the coverage
criteria above are still met, an E0652 is eligible for reimbursement.
The trial of conservative therapy must be documented in the beneficiary's medical record before prescribing
any type of pneumatic compression device (E0650, E0651, E0652). This assessment may be performed by the
treating practitioner or any other licensed/certified medical professional (LCMP) directly involved in the
beneficiary's lymphedema treatment. The LCMP may not have any financial relationship with the DMEPOS
supplier providing the device. If the assessment is performed by an LCMP, the treating practitioner must
receive and review the report of the evaluation. In addition, the treating practitioner must sign and date the
report, and state concurrence or disagreement with the assessment. The signature date must be on or before the
prescription date.
A segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) is only covered when
the individual has unique characteristics which prevent them from receiving adequate satisfactory pneumatic
compression treatment using a nonsegmented device along with a segmented appliance or compression device
without manual control of the pressure in each chamber.
The only "unique characteristics" identified in the clinical literature that requires the use of an E0652 device is
lymphedema extending onto the chest, trunk and/or abdomen which has remained unresponsive to all other
therapies.
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.
A PCD coded as E0650 or E0651 is used for lymphedema or CVI. An E0650 compressor with a segmented
appliance/sleeve (E0671, E0672, E0673) is considered functionally equivalent to an E0651 compressor with a
segmented appliance/sleeve (E0667, E0668, E0669).
You can find this information in Medicare's 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.