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Coverage criteria policies

Pneumatic compression devices and heat/cold therapy units – Minnesota Health Care Programs

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/ heat therapy units.

Coverage

Pneumatic compression devices are generally covered subject to the indications listed below and per your plan documents.

Cold/ heat therapy units are not considered medically necessary and are therefore not covered.

Indications that are covered

  1. Only compressors approved by the Food and Drug Administration (FDA) are covered. Only appliances approved by the FDA for use on extremities are covered.
  2. Non segmental pneumatic compression devices (E0650) and segmental pneumatic compression devices without calibrated gradient pressure (E0651), are covered for treatment of lymphedema when the member meets the following criteria:
    1. The member has undergone at least four weeks of conservative therapy. Conservative therapy includes:
      1. The use of appropriate compression bandage systems or compression garments
      2. Manual lymph massage
      3. Exercise
      4. Elevation of the limb
      5. Aggressive skin care
      6. Education in lymphedema self-management
    2. No significant improvement has occurred or significant symptoms remain following a four week trial.
  3. Non-segmental pneumatic compression devices (E0650), and segmental pneumatic compression devices without calibrated gradient pressure (E0651), are covered for treatment of chronic venous insufficiency of the lower extremities when the member has had one or more lower extremity venous stasis ulcers and meets the following criteria:
    1. The member has undergone at least six months of conservative therapy. Conservative therapy includes:
      1. The use of appropriate compression bandage systems or compression garments
      2. Appropriate dressings for the wound
      3. Exercise
      4. Elevation of the limb
      5. Aggressive skin care
    2. The venous stasis ulcer has failed to heal after a six month trial.

One segmental or non-segmental appliance for each affected extremity is covered per year for use with a medically necessary pneumatic compressor.

Segmental pneumatic compression devices with calibrated gradient pressure (E0652) are covered with authorization when the member’s medical condition cannot be safely and effectively treated with non-segmental devices or with segmental devices without calibrated gradient pressure.

Integrated appliances with 2 full legs and trunk (E0670) are covered with authorization for members that cannot use other appliances due to co-existing medical conditions, including obesity.

  1. High pressure, rapid cycling pneumatic compression devices (E0675) are covered for treatment of peripheral artery disease for patients who might otherwise require surgical treatment of the arterial insufficiency.

Indications that are not covered

  1. Appliances for use on the trunk, pelvis or chest (E0656, E0657) are not reimbursed separately from the compressor.
  2. Pneumatic compressors/appliances for indications other than peripheral artery disease, chronic venous insufficiency of the lower extremities or lymphedema are considered investigative.
  3. A pump for water circulating pad (E0236) is not covered. No evidence of superior outcomes for water circulating heat/cold pads vs standard treatment.
  4. A water circulating heat pad with pump (E0217) is not covered. No evidence of superior outcomes vs standard or moist heating pad.
  5. A pad for water circulating heat unit, for replacement only (E0249) is not covered. No evidence of superior outcomes for water circulating heat/cold pads vs standard treatment.

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. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Pneumatic Compression Devices. Revised 01-02-2013.
  2. Minnesota Health Care Programs (MHCP) Medical Supply Coverage Guide. Revised 04-09-2018.

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Policy activity

  • 05/02/2018 - Date of origin
  • 06/01/2018 - Effective date

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