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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 that PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, 
E0669, E0670, E0671, E0672, E0673) are eligible for reimbursement only when the appropriate, relat ed 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). 
 
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. 
 
I - LYMPHEDEMA 
 
A 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, and 
    2. 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, and 
    3. 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 PCD coded as E0650 or E0651 used to treat lymphedema 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 E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
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 PCD coded as E0650 or E0651 is covered for the treatment of CVI of the lower extremities only if the 
patient has all of the following: 
 
    Edema in the affected lower extremity 
    One or more venous stasis ulcer(s) 
    The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating 
practitioner. (See below for trial guidelines.) 
 
A PCD coded as E0650 or E0651 used to treat CVI 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 E0650 or E0651 used to treat ulcers in locations other than the lower extremity or ulcers and 
wounds from other causes is not eligible for reimbursement. Claims will be denied as not reasonable and 
necessary. 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 CVI 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. 
 
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.