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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 a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities 
alone. 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: 
1. The beneficiary has lymphedema of an extremity as defined above 
  
2. The coverage criteria for an E0650 or E0651 are met 
  
3. 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. 
  
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
  
The rules say that 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 rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
  
The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and 
E0650 or E0651 is required for coverage of E0652. You can find this rule in Local Coverage Determination 
(LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020. 
 
The rules say that contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) 
may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or 
she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome 
for the beneficiary. The physician or treating practitioner must document in the beneficiarys medical record 
the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. This documentation should include the following: 
 
1. The product's brand name or mode of delivery 
2. The features that this product or mode of delivery has versus other brand name products or modes of 
delivery; and 
3. An explanation of how these features are necessary to avoid an adverse medical outcome. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4. 
 
The rules say that if a physician or treating practitioner prescribes a particular brand or mode of delivery to 
avoid an adverse medical outcome, the contract supplier must either:  
 
1. Furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner; 
2. Consult with the physician or treating practitioner to find another appropriate brand of item or mode of 
delivery for the beneficiary and obtain a revised written prescription from the physician or treating practitioner; 
or 
3. Assist the beneficiary in locating a contract supplier that can furnish the particular brand of item or mode of 
delivery prescribed by the physician or treating practitioner. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4. 
 
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.