CurrentAetnaPolicy 0482

Compression Garments for the Legs

This clinical policy bulletin defines medical necessity, exclusions, coding, and background evidence for use of compression garments for the legs for Aetna members.

Policy Summary

PayerAetna

PolicyCompression Garments for the Legs

Policy CodePolicy 0482

Change TypeNo material change

Effective DateAug 24, 2001

Next Review DateMay 11, 2023

Key ActionConfirm coverage criteria are met before procuring HCPCS-coded gradient compression garments or pneumatic compressors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4max replacements/yr

2initial pairs

48RCTs (Cochrane)

4,321participants

57references

Coverage Criteria for Compression Garments — Legs

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Covered Indications

Aetna considers inflatable compression garments, non-elastic binders, or individually fitted prescription graded compression stockings medically necessary for members who have any of the following medical conditions:

Medically necessary indications: Treatment of complications of chronic venous insufficiency including lipodermatosclerosis; stasis dermatitis (venous eczema); varicose veins (except spider veins); venous edema; venous ulcers (stasis ulcers).

See ICD-10 list for covered diagnoses.

Medically necessary indications: Edema accompanying paraplegia or quadriplegia.

See ICD-10 list for covered diagnoses.

Medically necessary indications: Edema following surgery, fracture, burns, or other trauma.

Includes compression burn garments (custom fabricated) per HCPCS codes when selection criteria met.

Medically necessary indications: Lymphedema (see CPB 0069 - Lymphedema).

Pressure gradient support stockings or non-elastic leg binders may be used when selection criteria met.

Medically necessary indications: Post sclerotherapy (pressure gradient support stockings only).>= 18 mm Hg for pressure gradient support stockings

Only pressure gradient support stockings are considered medically necessary for this indication; inflatable garments have no proven value for this indication.

Medically necessary indications: Post-thrombotic syndrome (post-phlebitic syndrome).

See ICD-10 list for covered diagnoses.

Medically necessary indications: Postural hypotension.

See ICD-10 list for covered diagnoses.

Medically necessary indications: Prevention of thrombosis in immobilized persons (e.g., immobilization due to surgery, trauma, general debilitation).

Inflatable compression garments (with pump) are included when selection criteria are met.

Medically necessary indications: Severe edema in pregnancy.

See ICD-10 list for covered diagnoses.

Replacements and Initial Purchase

Replacements and initial purchase rules

Replacements and initial supply: Replacements are medically necessary when the compression garment cannot be repaired or when required due to a change in the member's physical condition.

Applies to inflatable garments, non-elastic binders, and pressure gradient support stockings when selection criteria met.

Pressure gradient support stockings quantity limits: For pressure gradient support stockings, no more than 4 replacements per year are considered medically necessary for wear.4 replacements/year

Maximum of 4 replacements per year for wear; second pair in initial purchase is for laundering use.

Initial purchase: Two pairs of compression stockings are considered medically necessary in the initial purchase.2 pairs

Experimental and Investigational

Compression garments are considered experimental and investigational for the following because effectiveness has not been established:

Experimental/Investigational: Improvement of functional performance in individuals with Parkinson disease.

Evidence is insufficient to support clinical benefit (see Southard et al. study).

Experimental/Investigational: Improvement of knee proprioception in rehabilitation settings.

Available studies show mixed findings; effectiveness not established for routine clinical use.

Experimental/Investigational: Management of delayed-onset muscle soreness (DOMS).

Randomized studies have not demonstrated consistent benefit of conventional compression garments for DOMS.

Experimental/Investigational:

Aetna's standard benefit plans generally do not cover graded compression stockings or non-elastic binders because these items are considered outpatient consumable or disposable supplies. Coverage for these items depends on the member's specific benefit plan; if the member's plan does provide coverage for graded compression stockings or non-elastic binders, medical necessity must be established by meeting the conditions listed in the "Covered Indications" section.

Compression garments for the legs are not covered or are considered experimental and investigational for several indications because effectiveness has not been established. Examples include: improvement of functional performance in Parkinson disease, improvement of knee proprioception in a rehabilitation setting, management of delayed-onset muscle soreness, management of pain during post‑natal care, and management of spasticity following stroke. In addition, garments are considered contraindicated and investigational in members with severe peripheral arterial disease or septic phlebitis. The ICD-10 list in the coding section also identifies specific diagnoses (for example, G20 — Parkinson's disease and arterial atherosclerosis codes) for which coverage is not provided for the indications listed.

Silver-impregnated compression stockings are considered not medically necessary because current evidence does not demonstrate superiority over standard compression stockings. As a result, these silver-impregnated products are not covered under the medical necessity criteria described in this policy.

Coding — HCPCS and ICD-10 Codes, Pressure Thresholds

HCPCS codes covered if selection criteria are metHCPCSCovered

A4465	Non-elastic binder for extremity.
A6507	Compression burn garment, foot to knee length, custom fabricated.
A6508	Compression burn garment, foot to thigh length, custom fabricated.
A6524-A6527	Gradient compression garment.
A6530-A6549	Gradient compression stocking.
A6552-A6564	Gradient compression stocking.
A6572-A6573	Gradient compression garment, toe caps.
A6583-A6587	Gradient compression wrap with adjustable straps.
A6594	Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each.
A6610	Gradient compression stocking, below knee, 18-30 mmhg, custom, each.

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1/2

HCPCS codes not covered / other related codesHCPCSNot Covered

E0675	Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system).
A6593	Accessory for gradient compression garment or wrap with adjustable straps, not-otherwise specified.
A6596-A6609	Gradient compression bandaging supply.

ICD-10 codes covered if selection criteria are metICD-10Covered

G81.00-G81.94	Hemiplegia and hemiparesis.
G82.20-G83.9	Paraplegia (paraparesis), quadriplegia (quadriparesis) and other paralytic syndromes.
I80.00-I80.209,I80.221-I80.3	Phlebitis and thrombophlebitis of superficial or deep vessels of lower extremities.
I83.001-I83.899	Varicose veins of lower extremities, with ulcer, with inflammation, with ulcer and inflammation, or with other complications.
I87.00-I87.099	Postthrombotic syndrome.
I87.2	Venous insufficiency (chronic)(peripheral).
I89.0-I89.9	Other noninfective disorders of lymphatic vessels and lymph nodes.
I95.1	Orthostatic hypotension.
O12.00-O12.05	Gestational edema.
O22.00-O22.03,O87.4	Varicose veins of lower extremity in pregnancy.

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ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

G20	Parkinson's disease.
I70.201-I70.299	Atherosclerosis of native arteries of the extremities.
I70.301-I70.799	Atherosclerosis of bypass graft of the extremities.
I73.00-I73.9,I77.70-I77.79	Other peripheral vascular disease.
I74.2-I74.4	Embolism and thrombosis of arteries of the extremities.
I77.1	Stricture of artery.
I77.89	Other specified disorders of arteries and arterioles.
M79.18	Myalgia, other site [delayed-onset muscle soreness].

Pressure threshold for prescription — inv-11: >= 18 mm Hg

Prescription pressure threshold>= 18 mm Hg

Applies toPre-made or custom pressure gradient support stockings (examples: Jobst, Juzo, SigVarus)

RequirementPhysician's prescription and measurements required for fitting

OTC stocking pressure threshold — inv-12: < 20 mm Hg

OTC stocking definitionStockings purchased over the counter without a prescription with pressure < 20 mm Hg

Coverage statusConsidered OTC and not covered (also experimental/investigational)

ExamplesElastic stockings, support hose, surgical leggings, anti-embolism stockings (Ted hose), pressure leotards

Provider Actions, Documentation, and Billing Guidance

Billing Rule

Coverage conditional on selection criteria

HCPCS codes in this policy are covered only when the selection criteria in the clinical coverage sections are met. Providers should confirm that all specific medical necessity criteria (including prescription, measurements, and required indications) are documented before submitting claims.

Affected HCPCS examples: A6610, A6524-A6527, A6530-A6549, A6552-A6564, A6583-A6587, A6594, A6572-A6573, A6465, A6507-A6508
See policy table of HCPCS codes for full list and coverage status

Note

Administrative notice

Aetna’s clinical policy bulletins are intended to guide administration of benefits and should be used by providers and plan administrators when determining coverage and claims handling for compression garments.

Refer to CPB 0069 (Lymphedema) and CPB 0500 (Intermittent Pneumatic Compression Devices) where applicable
Check member’s specific benefit plan for coverage details and any exclusions

Documentation Required

Preferred compression systems per evidence

Evidence favors multi-component compression systems (for example 2-, 3-, or 4-layer systems and high-compression stockings with an elastic component) over single-component systems for venous ulcer healing. When clinically appropriate, providers should prefer multi-component compression systems consistent with the evidence base and document rationale in the medical record.

Multi-component systems (including 4-layer bandage, 3-component systems with elastic components) associated with improved healing vs single-component or short-stretch alone
High-compression stockings with elastic components showed better healing at 2–4 months in pooled RCTs

Definitions and Device Descriptions

Non-elastic leg binder — inv-26: definition/key characteristic

DefinitionNon-elastic leg binder: a static-compression device using adjustable Velcro or buckle straps rather than elastic

Similarity to stockingsProvides static compression similar to graded compression stockings

ExamplesCircAid, LegAssist, Reid Sleeve

Pressure gradient support stockings — inv-27

DefinitionPressure gradient support stockings: pre-made or custom stockings with pressure >= 18 mm Hg

Prescription and fittingRequire a physician's prescription and measurements for fitting

ExamplesJobst, Juzo, SigVarus, Venes

Intermittent calf compression — inv-28

DefinitionIntermittent calf compression (ICLF): cyclic pneumatic compression applied to the calf to mimic the muscle pump

Typical cycle parametersExample cycle: 4 seconds on / 11 seconds off

Pressure rangesUsed with variable pressure ranges (e.g., 0–30 mmHg and 0–60 mmHg) depending on device and indication

DEFO — inv-29

DefinitionDEFO (dynamic elastomeric fabric orthoses): lycra-based compression garments designed for pre-natal and post-natal support

PurposeIntended to improve compliance compared with traditional maternity support belts and to manage pain/improve function

DescriptorsIncludes hosiery, support belts, abdominal binders and similar lycra-based garments

OpenPayer

Compression Garments for the Legs

Coverage Criteria for Compression Garments — Legs

Coding — HCPCS and ICD-10 Codes, Pressure Thresholds

Provider Actions, Documentation, and Billing Guidance

Background and Evidence Summary

Definitions and Device Descriptions