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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 state that a PCD coded as E0650 or E0651 is covered for the treatment of chronic venous 
insufficiency (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 six-month trial of conservative therapy demonstrating failed response to treatment is required. The six-month 
trial of conservative therapy must include all of the following: 
 
    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. 
    Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
    Regular exercise 
    Elevation of the limb 
    Appropriate wound care for the ulcer (including sharp debridement where appropriate) 
 
At the end of the six-month trial, if there has been improvement, then reimbursement for a PCD is not 
reasonable and necessary. Where improvement has occurred, the trial of conservative therapy must be 
continued with subsequent reassessments. When no significant improvement has occurred for a continuous 
period of six months and the coverage criteria above are still met, then the use of a PCD to treat CVI 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 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 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.