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Coverage criteria policies

Compression support garments

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for compression support garments.

Coverage

Compression garments are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Must be part of a treatment plan for venous insufficiencies, or to decrease contractures related to burns, which could result in a physical functional loss.
  2. Conditions for which compression support garments (ready or custom made) may be indicated include, but are not limited to, the following:
    1. Varicose veins
    2. Venous ulcers (also referred to as stasis ulcers)
    3. Venous insufficiency
    4. Stasis dermatitis
    5. Peripheral edema
    6. Varicosities of pregnancy
    7. Orthostatic hypotension
    8. Thrombophlebitis
    9. Lymphedema
  3. Ready-made or custom-made compression support garments, such as JOBST, Medi Strumpf, Sigvaris, ReidSleeve and CircAid compressions devices.
  4. Legacy compression garments are covered and indications for use are: lymphostatic low-flow, high-protein edema or radiation fibrosis.
  5. Four garments per affected limb (leg or arm) are covered per 12 month period, regardless of brand name (unless member has burns or post-mastectomy lymphedema – then see #6). When both legs and arms are affected, 4 pairs are covered per 12 months. When only one leg or arm is affected, 2 pairs – 4 individual stockings – are covered per 12 month period. The 12 month period is calculated using a “rolling year” (a period of 12 months that begins and ends on a set day). The 12 month period for garment limits begins on the date of the first (or most recent) purchase and extends for 12 months.
  6. Compression garments in excess of the limits in number 5 are covered when both of the following conditions are met:
    1. The additional compression garments are ordered by a physician; and
    2. The garments are used:
      1. for burn patients to decrease contractures, or
      2. to treat post-mastectomy lymphedemas.
  7. Miscellaneous items, such as garters, zippers or adhesive lotions are covered when deemed essential to the use of the garment.
  8. Stocking liners, when used for ulcer care, are covered and are limited to six per involved area per 12 month period (liners are sold three to a box).
  9. Compression / lymphedema bandages are covered for intractable lymphedema of the extremities. Garment quantity limits do not apply to these bandages. Bandages & compression garments may be covered at the same time if medically necessary.

Indications that are not covered

  1. T.E.D.™ hose or anti-embolism elastic support hose.
  2. Items which are primarily for comfort, convenience or recreation are excluded from coverage.
  3. Garments when used to decrease scarring for cosmetic purposes.
  4. Compression garments for the abdomen, chest, genitals, trunk or neck, are considered experimental and investigational for any indication other than burns or post-mastectomy lymphedema. There is a lack of peer-reviewed published literature evaluating the clinical utility of compression garments for these anatomical sites. Examples of these types of garments include vests, such as the Tribute® vest or torso garment (Solaris, West Allis, WI). (Please refer to the Breast Prosthesis coverage policy for coverage of mastectomy bras. See Related Content at right for link.)

Definitions

Anti-Embolism Stockings (e.g., T.E.D.™ hose) usually provide 8–18mmHg of compression and can be purchased over the counter without a prescription. Anti-embolism stockings are designed specifically for non-ambulatory (bed bound) patients. These are intended for short term wear during hospitalization to help prevent blood from pooling in the legs, which can lead to blood clots. They provide a lower level of compression than graduated/gradient compression stockings.

Compression support garments (sometimes referred to as lymphedema garments) decrease swelling by increasing the blood return to the heart. They are designed to promote and restore normal fluid circulation in patients with swelling due to lymphedema. They include arm sleeve, glove/gauntlet, stocking, foot cap, and pantyhose styles. They may be elastic or non-elastic. Non-elastic compression garments utilize a non-elastic textile that is fastened by adjustable hooks and loops to provide compression. They can be worn during the day or night. Both custom-made and prefabricated garments are available.

Compression garments are also used for severe burns to decrease scarring which can cause contractures, therefore preventing physical functional loss. They are tightly fitted garments and can be purchased off the shelf or custom made.

Compression / lymphedema bandages are minimally elastic (short-stretch) bandages which provide adequate tissue pressure to prevent reaccumulation of lymphedema.

Edema is swelling that is caused by excess tissue fluid that has not yet returned to the circulatory system. This can occur as a normal response to injury (such as a sprained ankle), or due to circulatory system problems such as chronic venous insufficiency or congestive heart failure. Swelling usually occurs in the lower areas of the body (legs and feet).

Graduated (also called Gradient or Graded) Compression Stockings are specialized hosiery that provide graduated pressure on the lower legs and feet to help prevent thrombosis (blood clots). They use stronger elastics to create significant pressure (usually 30-70 mm Hg) on the legs, ankles and feet. Graduated compression stockings should be tightest at the ankles and gradually become less constrictive toward the knees and thighs. They are available by prescription only and are used to treat venous and lymphatic disorders in ambulatory patients. They are used for all stages of chronic venous insufficiency, including varicose veins, edema, stasis skin changes and venous (sometimes called stasis) ulcers. They may also be used in preventing and treating post-thrombotic syndrome.

Long-stretch bandages contain elastic fibers that enable stretching to approximately 140% to 300% of their original length. Ace™ bandages are an example. These bandages stretch as edema increases. They also provide little resistance to calf-muscle contraction. Therefore, they have low working pressure, do not promote calf-muscle pump, and provide poor edema containment.

Lymphedema is swelling caused by excess protein-rich lymph trapped within the tissues. Lymphedema is caused by damage to the lymphatic system (such as removal of lymph nodes due to breast cancer) and the swelling occurs near the affected area.

Phlebitis is inflammation of a vein.

Short-stretch bandages are woven with cotton fibers and stretch to about 30% to 60%. Examples include the Rosidal K® and Comprilan® bandages typically used in lymphedema management. A short-stretch system used in venous ulcer management is the Coban™ 2 layer compression system. Multilayered short-stretch bandaging systems cause high working pressure, as they do not allow the calf muscles to bulge outward when they contract, generating inward pressure which forces venous return. Multilayered short-stretch bandages also act as a semi-rigid force to prevent expansion of edema. They offer excellent containment of all forms of edema.

Thrombophlebitis is an inflamed vein, with or without a small blood clot inside the vein. Thrombophlebitis is commonly just called phlebitis. Thrombophlebitis in a varicose vein develops as a tender hard knot in the vein. There is often erythema (redness) and bleeding may occur as the reaction extends through the vein wall. It is common with venous stasis ulcers.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Surgical Stockings and Bandages

    Code

    Description

    A4490

    Surgical stockings above knee length, each

    A4495

    Surgical stockings thigh length, each

    A4500

    Surgical stockings below knee length, each

    A4510

    Surgical stockings full length, each

    A6448

    Light compression bandage, elastic, knitted/woven, width less than 3 in, per yard

    A6449

    Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in and less than 5 in, per yard

    A6450

    Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 in, per yard

    A6451

    Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 ft lbs at 50% maximum stretch, width greater than or equal to 3 in and less than 5 in, per yard

    A6452

    High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 ft lbs at 50% maximum stretch, width greater than or equal to 3 in and less than 5 in, per yard

Burn Garments

    Code

    Description

    A6501

    Compression burn garment, bodysuit (head to foot), custom fabricated

    A6502

    Compression burn garment, chin strap, custom fabricated

    A6503

    Compression burn garment, facial hood, custom fabricated

    A6504

    Compression burn garment, glove to wrist, custom fabricated

    A6505

    Compression burn garment, glove to elbow, custom fabricated

    A6506

    Compression burn garment, glove to axilla, custom fabricated

    A6507

    Compression burn garment, foot to knee length, custom fabricated

    A6508

    Compression burn garment, foot to thigh length, custom fabricated

    A6509

    Compression burn garment, upper trunk to waist, including arm openings (vest), custom fabricated

    A6510

    Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated

    A6511

    Compression burn garment, lower trunk including leg openings (panty), custom fabricated

    A6512

    Compression burn garment, not otherwise classified

    A6513

    Compression burn mask, face and/or neck, plastic or equal, custom fabricated

Gradient Compression Stockings/ Wraps

    Code

    Description

    A6530

    Gradient compression stocking, below knee, 18 - 30 mm Hg, each

    A6531

    Gradient compression stocking, below knee, 30 - 40 mm Hg, each

    A6532

    Gradient compression stocking, below knee, 40 - 50 mm Hg, each

    A6533

    Gradient compression stocking, thigh length, 18 - 30 mm Hg, each

    A6534

    Gradient compression stocking, thigh length, 30 - 40 mm Hg, each

    A6535

    Gradient compression stocking, thigh length, 40 - 50 mm Hg, each

    A6536

    Gradient compression stocking, full-length/chap style, 18 - 30 mm Hg, each

    A6537

    Gradient compression stocking, full-length/chap style, 30 - 40 mm Hg, each

    A6538

    Gradient compression stocking, full-length/chap style, 40 - 50 mm Hg, each

    A6539

    Gradient compression stocking, waist length, 18 - 30 mm Hg, each

    A6540

    Gradient compression stocking, waist length, 30 - 40 mm Hg, each

    A6541

    Gradient compression stocking, waist length, 40 - 50 mm Hg, each

    A6544

    Gradient compression stocking, garter belt

    A6545

    Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each

    A6549

    Gradient compression stocking/sleeve, not otherwise specified

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Armstrong, D. G., & Meyr, A. J. Compression therapy for the treatment of chronic venous insufficiency. In: UpToDate, Mills Sr., J. L., & Eidt, J. F. (Ed). UpToDate, Waltham, MA. Accessed on September 26, 2018.
  2. Engrav, L. H., Heimbach, D. M., Rivara, F. P., Moore, M. L., Wang, J., Carrougher, G. J., Gibran, N. S. (2010). 12-Year within-wound study of the effectiveness of custom pressure garment therapy. Burns, 36, 975-983. doi: 10.1016/j.burns.2010.04.014.
  3. Gloviczki, P., Comerota, A. J., Dalsing, M. C., Eklof, B. G., Gillespie, D. L., Glovisczki, M. L., … Wakefield, T. W. (2011). The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF). Journal of Vascular Surgery, 53(16S), 2S-48S. doi: 10.1016/j.jvs.2011.01.079.
  4. International Society of Lymphology (2016). The diagnosis and treatment of peripheral lymphedema: 2016 consensus document. Lymphology, 49, 170-184.
  5. Lim, C,, Davies A (2014) Graduated Compression Stockings, Canadian Medical Association Journal, 186 (10) : E391-E398.
  6. Mohler, E. R. III, & Mehrara, B. Clinical staging and conservative management of peripheral lymphedema. In: UpToDate, Eidt, J. F., Berman, R. S., & Mills Sr., J. L. (Ed), UpToDate, Waltham, MA. Accessed on October 12, 2018.
  7. NICE (2013). Varicose veins: diagnosis and management (clinical guideline). Retrieved from nice.org.uk/guidance/cg168.
  8. O’Donnell, T. F., Passman, M. A., Marston, W. A., Ennis, W. J., Dalsing, M., Kistner, R. L., Gloviczki, P. (2014). Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF): Management of venous leg ulcers. Journal of Vascular Surgery, 60, 3S-59S. doi: doi.org/10.1016/j.jvs.2014.04.049.
  9. O’Meara, S., Cullum, N., Nelson, E. A., & Dumville, J. C. (2012). Compression for venous leg ulcers. Cochrane Database of Systematic Reviews, 11, 1-192. doi: 10.1002/14651858.CD000265.pub3.
  10. Wound, Ostomy, and Continence Nurses Society. (2017). Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide , Mt. Laurel, NJ

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Policy activity

  • 01/01/1994 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 10/2018
Revision date
  • 11/03/2016

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