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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 
 
 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. 
 
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. The only unique characteristics identified in the 
clinical literature that requires the use of an E0652 device is lymphedema extending onto the chest, trunk 
and/or abdomen which has remained unresponsive to all other therapies. 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 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.