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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 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, in-
person fitting, training and supervision by a technician who is skilled in and who regularly and successfully 
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. 
 
You can find this information in the 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.