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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 pneumatic compression device (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 enrollee has a diagnosis of lymphedema as defined above, and 2. 
The enrollee 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. 
A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-
week trial of conservative therapy must include all of the following: regular and 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 and elevation of the limb. 
 
A pneumatic compression device (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. 
? The coverage criteria for an E0650 or E0651 PCD 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. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
PCD 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 PCD 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 
? 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 hypoproteinemia 
 
 
 
You can find this information at 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.