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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 pneumatic compression device (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: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. 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 
3. 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. 
A segmented, calibrated gradient pneumatic compression device (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. 
 
PCD related accessories (E0667) 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 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.