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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 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). 
 
Primary lymphedema: 
 
Primary lymphedema is a disorder of the lymphatic system that occurs on its own. It is inherited and 
uncommon. Examples (not all-inclusive) are: 
 
    Congenital lymphedema due to lymphatic aplasia or hypoplasia 
    Milroy's disease, an autosomal dominant familial form of congenital lymphedema 
    Lymphedema praecox 
    Lymphedema tarda 
 
Secondary lymphedema: 
 
Secondary lymphedema is a disorder of lymphatic flow that is caused by some other disease or condition. It is 
more common than primary lymphedema. It is most commonly caused by surgery (especially lymph node 
dissection, such as for breast cancer), radiation therapy (especially axillary or inguinal), trauma, lymphatic 
obstruction by tumor, and, in developing countries, lymphatic filariasis. Secondary lymphedema may also 
result from compression of the lymphatic and venous channels resulting from leakage of fluid into interstitial 
tissues in patients with chronic venous insufficiency. (See below) 
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. 
 
I - LYMPHEDEMA 
 
A 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 
    3. 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 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 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 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. 
 
Four-Week Trial for Lymphedema Extending Onto the Chest, Trunk and/or Abdomen 
 
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. 
 
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.