Appeal type: unknown
Decision: unknown

 
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 pneumatic compression devices are covered only when prescribed by a physician and when they 
are used with appropriate physician oversight, i.e., physician evaluation of the patient's condition to determine 
medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan 
defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and 
response to treatment. 
 
The determination by the physician of the medical necessity of a pneumatic compression device must include: 
 
    The patient's diagnosis and prognosis; 
    Symptoms and objective findings, including measurements which establish the severity of the condition; 
    The reason the device is required, including the treatments which have been tried and failed; and 
    The clinical response to an initial treatment with the device. 
 
The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment 
session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the 
home. The only time that a segmented, calibrated gradient pneumatic compression device (HCPCs code 
E0652) would be covered is when the individual has unique characteristics that prevent them from receiving 
satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented 
appliance or a segmented compression device without manual control of pressure in each chamber. You can 
find this information in Medicare's National Coverage Determination (NCD): Pneumatic Compression Devices 
(280.6). 
 
The rules say 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. The trial of conservative therapy must be 
documented in the beneficiarys 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 beneficiarys 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. 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.