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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 Prescriptions for Pneumatic Compression Devices (PCDs) (E0650, E0651, E0652, E0675,
E0676) are limited to Physicians (MD, DO, DPM) and physician extenders (NP, PA, CNS) to the extent
allowed by their applicable state scope-of-practice and other license requirements. Providers must use care
because the treatment of lymphedema, chronic venous insufficiency with ulceration and complications related
to the treatment of these conditions by use of PCDs, commonly require consideration of diagnoses and
management of systemic conditions. In no event should a provider order PCDs or PCD appliances that are to be
used for or are to be applied to areas of the body that fall outside of their state scope of practice and other
license limitations.
Lymphedema, as discussed below, is just one group of conditions that can be a cause of accumulation of fluid
in the tissue. Lymphedema arises from disorders of the lymphatic system. It is essential to rule out other causes
of edema in order to diagnose lymphedema. Edema from other causes is not classified as lymphedema for
purposes of Medicare reimbursement for PCDs (E0650, E0651, E0652).
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.
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 E0652 is not covered for the treatment of CVI 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.
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.
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 non-segmented 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.
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 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.