Pneumatic devices are covered for the treatment of lymphedema or for the
treatment of chronic venous insufficiency with venous stasis ulcers.

**Lymphedema**

Lymphedema is the swelling of subcutaneous tissues due to the accumulation of
excessive lymph fluid. The accumulation of lymph fluid results from impairment
to the normal clearing function of the lymphatic system and/or from an
excessive production of lymph. Lymphedema is divided into two broad classes
according to etiology. Primary lymphedema is a relatively uncommon, chronic
condition which may be due to such causes as Milroy's Disease or congenital
anomalies. Secondary lymphedema, which is much more common, results from the
destruction of or damage to formerly functioning lymphatic channels, such as
surgical removal of lymph nodes or post radiation fibrosis, among other
causes.

Pneumatic compression devices are covered in the home setting for the
treatment of lymphedema if the patient has undergone a four-week trial of
conservative therapy and the treating physician determines that there has been
no significant improvement or if significant symptoms remain after the trial.
The trial of conservative therapy must include use of an appropriate
compression bandage system or compression garment, exercise, and elevation of
the limb. The garment may be prefabricated or custom-fabricated but must
provide adequate graduated compression.

**Chronic Venous Insufficiency With Venous Stasis Ulcers**

Chronic venous insufficiency (CVI) of the lower extremities is a condition
caused by abnormalities of the venous wall and valves, leading to obstruction
or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation,
stasis dermatitis, chronic edema, and venous ulcers.

Pneumatic compression devices are covered in the home setting for the
treatment of CVI of the lower extremities only if the patient has one or more
venous stasis ulcer(s) which have failed to heal after a 6 month trial of
conservative therapy directed by the treating physician. The trial of
conservative therapy must include a compression bandage system or compression
garment, appropriate dressings for the wound, exercise, and elevation of the
limb.

**General Coverage Criteria**

Pneumatic compression devices are covered only when prescribed by a physician
and when they are used with appropriate physician oversight, i.e., physician
evaluation of the patient's condition to determine medical necessity of the
device, assuring suitable instruction in the operation of the machine, a
treatment plan defining the pressure to be used and the frequency and duration
of use, and ongoing monitoring of use and response to treatment.

The determination by the physician of the medical necessity of a pneumatic
compression device must include:

  1. The patient's diagnosis and prognosis;
  2. Symptoms and objective findings, including measurements which establish the severity of the condition;
  3. The reason the device is required, including the treatments which have been tried and failed; and
  4. The clinical response to an initial treatment with the device. 

The clinical response includes the change in pre-treatment measurements,
ability to tolerate the treatment session and parameters, and ability of the
patient (or caregiver) to apply the device for continued use in the home.

The only time that a segmented, calibrated gradient pneumatic compression
device (HCPCs code E0652) would be covered is when the individual has unique
characteristics that prevent them from receiving satisfactory pneumatic
compression treatment using a nonsegmented device in conjunction with a
segmented appliance or a segmented compression device without manual control
of pressure in each chamber.