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Decision: unknown

 
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 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. 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. 
 
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 is 
required. The four-week trial of conservative therapy must include all of the following: 
 
1. 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. 
 
2. Regular exercise 
3. Elevation of the limb 
 
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
 
The rules say that in order to justify payment for pneumatic compression devices, suppliers must meet the 
following requirements: 
 
1. Standard written order 
2. Medical record information (including continued need/use if applicable) 
3. Correct coding 
4. Proof of delivery 
 
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
 
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.