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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 segmented, calibrated gradient PCD (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 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 heart failure) 
- Correction (where possible) of anemia and/or hypoproteinemia 
 
The trial of conservative therapy must be documented in the beneficiarys medical record before prescribing 
any type of PCD (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 are eligible for reimbursement only when the appropriate, related base PCDs 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 these 
rules in 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.