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 that a segmented, calibrated gradient pneumatic compression device (PCD) (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 
chronic venous insufficiency (CVI) is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. 
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  
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. 
 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 
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. 
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 the Local Coverage Determination (LCD) for 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.