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Coverage criteria policies

Pneumatic compression devices

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific 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 required for pneumatic compression devices used in the home setting.

Prior authorization is not required for pneumatic compression devices received/ used in a surgical setting.

Prior authorization is not applicable for cold compression therapy.

Coverage

Pneumatic compression devices are generally covered per the indications listed below. The member must have a successful trial of the device in a clinical setting, or the device will be covered as a rental unit until it is determined that the treatment is effective and tolerated. Cold compression therapy is considered investigational/experimental and is therefore not covered.

Indications that are covered

Lymphedema treatment:

The use of segmented or non-segmented pneumatic compression device without calibrated gradient pressure (non-programmable pumps) are covered in the home setting for the treatment of extremity or truncal lymphedema if the member:

  1. Is under the care of a lymphedema specialist or program; and
  2. 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.
    1. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb.
    2. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.

The use of segmented or non-segmented pneumatic compression device with calibrated gradient pressure (non-programmable pumps, code E0652, pneumatic compressor, two phases with calibrated gradient pressure, e.g. Flexitouch) is allowed if the individual has unique characteristics (e.g., significant scarring) that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671- E0673) or a segmented device without manual control of the pressure in each chamber (E0651).

Chronic venous insufficiency (CVI) treatment:

Pneumatic compression devices are covered in the home setting for the treatment of CVI of the lower extremities only if the member has:

  1. One or more venous stasis ulcer(s) which have failed to heal after a six month trial of conservative therapy directed by the treating physician, and
  2. Undergone a trial of conservative therapy that includes:
    1. a compression bandage system or compression garment;
    2. appropriate dressings for the wound;
    3. exercise; and
    4. elevation of the limb.
Deep vein thrombosis (DVT) prevention:

Pneumatic compression device is covered to prevent deep vein thrombosis (DVT) when there is a contraindication to the use of anti-coagulation medication.

Peripheral arterial disease

The use of a pneumatic compression device, including intermittent compression device, is covered for members with peripheral arterial disease.

Indications not covered

  1. The use of a pneumatic compression device is not covered for any other indication.
  2. Cold compression therapy is not covered because there is no evidence that it is more effective than standard cold and compression therapy.

Definitions

ActiveCare +S.F.T is an example of an intermittent compression device that utilizes Synchronized Flow Technology. This technology enables the detection and monitoring of the respiratory related venous phasic flow. Once detected, the technology will trigger compression of the vein so that it will be in phase with the venous phasic flow. Since the venous phasic flow is at its peak when the common femoral vein is open and flow is not disturbed by a descending diaphragm (such as when inhaling) this technology enhances the Peak Venous Velocity generated by the device.

Cold compression therapy is performed by a durable medical equipment (DME) device with a combination of active compression and cooling, as well as conformable, form-fitting anatomic wraps, and adjustable pressure and temperature settings. Brand names include but are not limited to Game Ready, CryoCuff, Aircast, IceMan, PolarCare, etc.

Complex lymphedema therapy (CLT) is a noninvasive treatment used as a rehabilitative intervention for chronic lymphedema that does not respond to other treatments. This method has also been referred to as complete decongestive physiotherapy (CDP). The treatment aim is to reduce and control the amount of swelling in the affected limb, as well as to restore function and improve appearance. Initial gentle massage of the healthy quadrant is followed by manipulation of the affected extremity, beginning with the base of the limb and progressing to the distal aspect. Programs are generally provided on an outpatient basis in the office setting or in a lymphedema rehabilitation center or clinic.

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 (backflow) of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.

Deep Vein Thrombosis (DVT) is a condition in which a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. Deep vein thrombosis can cause leg pain, but often occurs without any symptoms.

Intermittent pneumatic compression devices prevent venous thrombosis by enhancing blood flow in the deep legs of the veins, thereby preventing venous stasis. They also reduce plasminogen activator inhibitor-1 thereby increasing endogenous fibrinolytic activity.

Lymphedema is the swelling of the subcutaneous (just below the skin) tissues caused by obstruction of the lymphatic drainage. It results from lymph fluid accumulation and may arise from surgery, radiation, trauma, infection, the presence of a tumor in the area of the lymph nodes, or congenital malformation of the lymphatic system. Inadequately treated lymphedema is associated with serious infection (cellulitis), hardening of tissues (fibrosis), impaired skin integrity and compromised mobility.

Lymphedema Pumps:

  • Non segmented pneumatic compressor has a single outflow port on the compressor which can be connected to a single or multiple compartment sleeves. The latter makes it similar to a segmented pneumatic compressor.
  • Segmented pneumatic compressor has multiple outflow ports that lead to distinct segments on the appliance which inflate in a sequential manner. The device can be with or without calibrated pressure.
  • Two-phase lymph preparation and drainage therapy device, such as the Flexitouch® Lymphedema System which features a 2-Phase Lymph Preparation & therapy system™Drainage. The Flexitouch Lymphedema System can be used on both the lower leg and trunk and the upper arm and trunk. For both applications, light tactile pressure is applied first and then drainage commences. The inflatable chambers of the Flexitouch garment inflate and deflate in a preset pattern that is similar to manual lymph drainage (MLD) therapy. During the lymph preparation phase, a light pressure is applied to the trunk at the chest area and/or lower abdomen area. This action assists the lymphatic system in the trunk to direct fluid from affected lymphatic regions to unaffected regions. During lymph drainage, fluid is moved out of the limb and into the venous system. The soft, stimulating action is similar to MLD therapy.”2

Venous thromboembolism (VTE) refers to deep vein thrombosis (DVT) or pulmonary embolism (PE). Risk of DVT increases due to venous stasis of the lower limbs as a consequence of immobility during or after surgery. Patients who have major orthopedic surgery (such a total hip arthroplasty, total knee arthroplasty and hip fracture surgery) are at particularly high risk. While most DVTs are asymptomatic and generally resolve when mobility is restored, some acute DVTs can be associated with substantial morbidity. The most serious adverse consequence of an acute DVT is a PE, which occurs when a DVT detaches and migrates to the lungs. Antithrombotic prophylaxis is recommended for patients undergoing major orthopedic surgery and for other surgical patients at increased risk of VTE.

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.

Covered ICD-10-CM Codes when coverage criteria are met:

Codes

Description

I87.2

Venous insufficiency (chronic)

I89.0- I89.9

Other noninfective disorders of lymphatic vessels and lymph nodes

I97.2

Postmastectomy lymphedema syndrome

Q82.0

Hereditary lymphedema

Covered HCPCS Codes when coverage criteria are met:

Codes

Description

E0650

Pneumatic compressor, nonsegmental home model

E0651

Pneumatic compressor, segmental home model without calibrated gradient pressure

E0652

Pneumatic compressor, segmental home model with calibrated gradient pressure

E0655

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

E0656

Segmental pneumatic appliance for use with pneumatic compressor, trunk

E0657

Segmental pneumatic appliance for use with pneumatic compressor, chest

E0660

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

E0665

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

E0666

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

E0667

Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0668

Segmental pneumatic appliance for use with pneumatic compressor, full arm

E0669

Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0670

Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk

E0671

Segmental gradient pressure pneumatic appliance, full leg

E0672

Segmental gradient pressure pneumatic appliance, full arm

E0673

Segmental gradient pressure pneumatic appliance, half leg

E0675

Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)

E0676

Intermittent limb compression device (includes all accessories), not otherwise specified

Non-covered HCPCS Codes:

Codes

Description

E0218

Water circulating cold pad with pump

E0236

Pump for water circulating pad

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

  • Items must be received from a contracted vendor for in-network benefits to apply.
  • Full line vendors provide a wide range of equipment and supplies, such as hospital beds, aids for ambulating and toileting, phototherapy lights, wheelchairs, custom seating devices, monitors, pumps, oxygen and etc.

References:

  1. Centers for Medicare & Medicaid Services. (2016, July). Local Coverage Determination (LCD): Pneumatic compression devices (L33829). Retrieved from link.
  2. Fife, C. E., Davey, S., Maus, E. A., Guilliod, R., & Mayrovitz, H. N. (2012). A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home. Support Care Cancer, 20(12), 3279-3286. doi 10.1007/s00520-012-1455-2
  3. Hayes, Inc. Hayes Health Technology Brief. Pneumatic Compression Devices for Treatment of Peripheral Lymphedema.
  4. PA: Hayes, Inc.; June, 2005. Reviewed January, 2008/ Archived January, 2009.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Intermittent Pneumatic Compression for Peripheral Arterial Disease. Lansdale, PA: Hayes, Inc.; July, 2013. Reviewed May, 2016.
  6. Hayes, Inc. Hayes Health Technology Brief. Cold Compression Therapy for Orthopedic Conditions. Lansdale, PA: Hayes, Inc.; December, 2013. Reviewed November, 2015.
  7. Hubbard, T. J., Aronson, S. L., & Denegar, C. R. (2004). Does cryotherapy hasten return to participation? A systematic review. Journal of Athletic Training, 39(1), 88–94
  8. Jobin, S., Kalliainen, L., Adebayo, L., Agarwal, Z., Card, R., Christie, B., … Morton C. Institute for Clinical Systems Improvement. Venous Thromboembolism Prophylaxis. http://bit.ly/VTEProphy1112. Updated November 2012.
  9. Pai, M., Prevention of venous thromboembolic disease in surgical patients. In: UpToDate, Leung, L. L. K., & Mandel, J. (Eds), UpToDate, Waltham, MA. (Accessed on May 2, 2017.)

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Policy activity

  • 04/12/2016 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 03/2017
Revision date
  • 08/31/2017

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