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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 Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say Pneumatic Compression Devices (PCDs) coded as E0650, E0651, E0652 are used only in the 
treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
Reimbursement for these items is based upon the criteria in the following sections. PCD coded as E0675 is 
used in the treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and 
necessary as outlined below. 
 
I - LYMPHEDEMA 
 
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: 
 
    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. (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 
 
You can find this information in Medicare's 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.