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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 E0650 or E0651 is covered for both primary and secondary lymphedema in 
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 
 
The beneficiary has a diagnosis of lymphedema as defined above, and 
The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of 
at least one of the following clinical findings: 
Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
Papillomatosis cutis lymphostatica, 
Deformity of elephantiasis, 
Skin breakdown with persisting lymphorrhea, 
Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a 
likely etiology, and 
In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
A PCD coded as E0650 or E0651 used to treat lymphedema 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 E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
 
A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the 
criteria in this section are met. Claims will be denied as not reasonable and necessary. Refer below to the 
sections III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN and PCD 
Code Selection for additional information about the limited coverage for PCD coded as E0652. 
 
Four-Week Trial for Lymphedema 
 
A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-
week trial of conservative therapy must include all of the following:  
Regular and 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 of the limb 
When available, manual lymphatic drainage is a key component of conservative treatment as is appropriate 
medication treatment when there is concurrent congestive heart failure. 
 
The medical necessity determination for a PCD by the treating practitioner must include symptoms and 
objective findings, including measurements, to establish the severity of the condition. 
 
The documentation by the treating practitioner of the medical necessity of a PCD must include: 
 
The patients 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 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. 
 
You can find this information in the 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.