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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 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:  
o Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
o Papillomatosis cutis lymphostatica, 
o Deformity of elephantiasis, 
o Skin breakdown with persisting lymphorrhea, 
o 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 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. 
Four-Week Trial for Lymphedema 
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: 
&#61623; Regular and compliant use of an appropriate compression bandage system or compression garment to 
provide adequate graduated compression  
o 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. 
o The garment may be prefabricated or custom-fabricated but must provide adequate graduated 
compression starting with a minimum of 30 mmHg distally. 
&#61623; Regular exercise 
&#61623; Elevation of the limb 
When available, manual lymphatic drainage is a key component of conservative treatment as is appropriate 
medication treatment when there is concurrent congestive failure. 
 
 
At the end of the four-week trial, if there has been improvement, then reimbursement for a PCD 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. Only when no significant improvement has occurred in the most 
recent four weeks and the coverage criteria above are still met, may the lymphedema be considered 
unresponsive to conservative therapy, and coverage for a PCD considered. 
The medical necessity determination for a PCD by the treating practitioner must include symptoms and 
objective findings, including measurements, to establish the severity of the condition. 
The documentation by the treating practitioner of the medical necessity of a pneumatic compression device 
must include: 
&#61623; The patient?s diagnosis and prognosis; 
&#61623; Symptoms and objective findings, including measurements which establish the severity of the 
condition; 
&#61623; The reason the device is required, including the treatments which have been tried and failed; and 
&#61623; The clinical response to an initial treatment with the device 
At a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same 
manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials 
and therapy, with bilateral comparisons where appropriate. 
You can find this rule in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) 
effective January 1, 2020. 
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.