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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 Pneumatic Compression Devices (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 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:
The beneficiary has a diagnosis of lymphedema, and
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
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 E0650 or E0651 used to treat lymphedema 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 E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for
reimbursement. Claims will be denied as not reasonable and necessary.
A PCD coded as E0650 or E0651 is covered for the treatment of CVI of the lower extremities only if the
patient has all of the following:
Edema in the affected lower extremity
One or more venous stasis ulcer(s)
The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating
practitioner. A PCD coded as E0650 or E0651 used to treat CVI 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 E0650 or E0651 used to treat ulcers in locations other than the lower extremity or ulcers and
wounds from other causes is not eligible for reimbursement. Claims will be denied as not reasonable and
necessary.
PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671,
E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651,
E0652, E0675) meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered,
related accessories are not eligible for reimbursement. Claims for related items will be denied as not reasonable
and necessary.
You can find these rules in 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.