Appeal type: unknown
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, 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
- 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. 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. 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 covers items and services in accordance with Medicare rules.