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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 The only time that a segmented, calibrated gradient pneumatic compression device (HCPCs code E0652) would be covered is when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber. Pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patient's condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment. The determination by the physician of the medical necessity of a pneumatic compression device must include: 1. The patient's diagnosis and prognosis; 2. Symptoms and objective findings, including measurements which establish the severity of the condition; 3. The reason the device is required, including the treatments which have been tried and failed; and 4. The clinical response to an initial treatment with the device. You can find this information in Medicare's National Coverage Determination (NCD) for Pneumatic Compression Devices (280.6). The rules say that 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 nonsegmented device along with a segmented appliance or compression device without manual control of the pressure in each chamber. A segmented device with calibrated gradient pressure (E0652) is characterized by manual control on at least three outflow ports that can deliver an individually determined pressure to each corresponding appliance segment. Use of tubing and/or appliances that can create a pressure gradient independently from the compressor does not qualify to classify the compressor as E0652. These methods are not considered as calibrated gradient pressure. Appliances appropriate for use with an E0652 PCD are E0656, E0657, E0667, E0668, E0669 and E0670. You can find this information in Medicare's Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). The rules say that as a condition for payment, 42 CFR 410.38 and Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a beneficiary within the six (6) months prior to prescribing items that appear on the Required List.
The face-to-face encounter must support payment for the item(s) ordered/prescribed, and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered. This face-to-face requirement also includes examinations conducted via the CMS-approved use of telehealth examinations, which must meet the requirements of 42 CFR  410.78 and 414.65 for purposes of DMEPOS coverage. A WOPD must be completed within six (6) months after the required face-to-face encounter. You can find this information in Medicare's Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.