E0658 Segmental Pneumatic Appliance Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II E0658: Segmental Pneumatic Appliance for 2 Arms and Chest

HCPCS Level II code E0658 represents an integrated segmental pneumatic appliance configured for two full arms and the chest, used with a pneumatic compressor to deliver sequential compression therapy. Nationally, this code matters for coverage and reimbursement of durable medical equipment for conditions requiring upper‑extremity and thoracic compression, including lymphedema management and venous insufficiency therapies. Payer coverage policies and documentation requirements drive access and utilization across care settings.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. Readers will find a concise overview of the code’s clinical purpose and typical site of service, common payer coverage patterns and benchmarks, relevant policy drivers affecting reimbursement and documentation, and practical notes on claim submission and billing considerations. The publication summarizes typical utilization contexts, distinctions in payer coverage frameworks, and the clinical scenarios in which this appliance is most commonly deployed.

This material is intended to inform billing staff, DME suppliers, clinicians involved in lymphedema and vascular care, and policy analysts about the national policy and billing context for E0658 so stakeholders can align documentation and submission practices with prevailing payer expectations.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareE0658HCPCS Level IIdurable medical equipmentpneumatic compressionlymphedemaupper extremityoutpatienthome health

Billing Code Overview

HCPCS Level II code E0658 describes a segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest. This device is a multi-chambered, inflatable garment designed to provide sequential pneumatic compression to the bilateral upper extremities and thoracic region.

Service type: Durable Medical Equipment — pneumatic compression therapy appliance

Typical site of service: Home or outpatient setting where durable medical equipment is provided and used

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with bilateral upper extremity and chest lymphedema following mastectomy and axillary lymph node dissection is referred for segmental pneumatic compression therapy. The durable medical equipment (DME) supplier fits an integrated pneumatic appliance consisting of two full arms and a chest garment designed to connect to a pneumatic compressor. Prior to delivery, the DME clinical staff verifies written physician order specifying code E0658, reviews recent clinical notes documenting lymphedema stage and functional limitation, obtains measurements for garment sizing, and provides patient education on donning, doffing, cleaning, and daily use. The device is delivered and demonstrated in the clinic or patient home; the supplier documents training, appliance serial number, and patient acknowledgment. Follow-up occurs by the prescribing clinician or lymphedema therapist to assess response and adjust the regimen, with potential repeat documentation for continued medical necessity at periodic intervals.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When unusually complex fitting or extended professional services are required for appliance delivery and justification is documented.

HCPCS Level II E0442: Stationary Liquid Oxygen, 1-Month Supply

HCPCS-E1560-BLOOD-LEAK-DETECTOR-HEMODIALYSIS-REPLACEMENT

HCPCS Level II E1560: Blood Leak Detector for Hemodialysis, Replacement

HCPCS-E0464-PRESSURE-SUPPORT-VENTILATOR-NONINVASIVE

HCPCS E0464: Pressure Support Ventilator for Non-Invasive Use

HCPCS-E0450-VOLUME-CONTROL-VENTILATOR-INVASIVE-INTERFACE

HCPCS E0450: Volume Control Ventilator for Invasive Interface

HCPCS-E0167-COMMODE-PAIL-PAN-REPLACEMENT

HCPCS Level II E0167: Pail or Pan for Commode Chair, Replacement Only

HCPCS-E0430-PORTABLE-GASEOUS-OXYGEN-SYSTEM-PURCHASE

HCPCS E0430: Portable Gaseous Oxygen System, Purchase

HCPCS-E1234-PEDIATRIC-TILT-IN-SPACE-FOLDING-WHEELCHAIR

HCPCS Level II E1234: Pediatric Tilt-in-Space Folding Wheelchair

HCPCS-E2310-POWER-WHEELCHAIR-SEATING-CONNECTION-ACCESSORY

HCPCS E2310: Power Wheelchair Seating Connection Accessory

HCPCS-E2213-WHEELCHAIR-PNEUMATIC-TIRE-INSERT-REMOVABLE

HCPCS E2213: Manual Wheelchair Pneumatic Tire Insert, Removable

HCPCS-E2225-WHEELCHAIR-CASTER-WHEEL-REPLACEMENT

HCPCS E2225: Manual Wheelchair Caster Wheel, Replacement

Showing 1–10 of 670

52

Taxonomy Code	Specialty	Notes
`333600000X`	Physical Therapist	Commonly involved in lymphedema assessment and training for pneumatic device use.
`334800000X`	Occupational Therapist	Provides upper extremity function training and assists with garment application strategies.
`332B00000X`	Durable Medical Equipment Supplier	DME vendor specialty responsible for fitting, delivery, and patient education.
`207L00000X`	Lymphedema Therapist (Physical Therapy Subspecialty)	Clinicians with lymphedema certification performing specialized fitting and regimen planning.
`207Q00000X`	General Surgeon	May prescribe the appliance post-mastectomy and coordinate ongoing follow-up.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I89.0`	Lymphedema, not elsewhere classified	Primary indication for segmental pneumatic compression to reduce limb and chest wall edema.
`C50.911`	Malignant neoplasm of unspecified site of right female breast	Postoperative patients with breast cancer often develop secondary lymphedema requiring compression therapy.
`C50.912`	Malignant neoplasm of unspecified site of left female breast	As above, left-sided breast cancer with subsequent lymphedema affecting arm and chest.
`Z89.611`	Acquired absence of right breast and nipple	Patients post-mastectomy with chest wall changes and lymphedema may require integrated chest-arm compression.
`Z89.612`	Acquired absence of left breast and nipple	Same clinical relevance for left-sided post-mastectomy lymphedema management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97162`	Physical therapy evaluation, moderate complexity	Used when a therapist evaluates lymphedema severity and documents need for segmental pneumatic compression prior to DME order.
`97110`	Therapeutic exercises, each 15 minutes	May be performed alongside compression therapy in outpatient rehabilitation to improve range of motion and strength.
`97140`	Manual therapy techniques (e.g., manual lymphatic drainage), each 15 minutes	Manual lymphatic drainage is commonly provided before or concurrent with pneumatic compression to enhance fluid mobilization.
`99070`	Supplies and materials provided by the physician over and above those usually included with the office visit	Used if additional disposable liners or garments are supplied by the clinic in association with fitting.
`99406`	Smoking and tobacco use cessation counseling, intermediate	Example ancillary service that may be documented in perioperative care; not directly linked but commonly billed in comprehensive care plans.

OpenPayer