Appeal type: unknown
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 a pneumatic compression device (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. 
 
A PCD coded as E0652 is not covered for the treatment of chronic venous insufficiency (CVI) 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. 
 
A segmented, calibrated gradient pneumatic compression device (Healthcare Common Procedure Coding 
System (HCPCS) code 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 CVI 
is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
PCD CODE SELECTION (E0650, E0651, E0652, E0675, E0676) 
 
A PCD coded as E0650 or E0651 is used for lymphedema or CVI. An E0650 compressor with a segmented 
appliance/sleeve (E0671, E0672, E0673) is considered functionally equivalent to an E0651 compressor with a 
segmented appliance/sleeve (E0667, E0668, E0669). 
 
A segmented, calibrated gradient pneumatic compression device (HCPCS code 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. 
 
The only unique characteristics identified in the clinical literature that requires the use of an E0652 device is 
lymphedema extending onto the chest, trunk and/or abdomen which has remained unresponsive to all other 
therapies. PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, 
E0670, E0671, E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs 
(E0650, E0651, E0652, E0675) 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 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.