Pneumatic Compression Devices (Preauthorization Required)
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Defines preauthorization and coverage guidance for pneumatic compression devices and related HCPCS codes for Blue Cross Blue Shield of Nebraska members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Clinical Guidance
Coverage criteria references — NCD and Milliman (MCG) clinical criteria
Coverage determinations reference an applicable National Coverage Determination (NCD) or Milliman (MCG) clinical criteria depending on the HCPCS code.
HCPCS Codes and NCD Applicability
| E0650 | Pneumatic compressor, non-segmental home model |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure |
| E0655 | Non-segmental 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 | Non-segmental pneumatic appliance for use with pneumatic compressor, full leg |
| E0665 | Non-segmental pneumatic appliance for use with pneumatic compressor, full arm |
| E0666 | Non-segmental pneumatic appliance for use with pneumatic compressor, half leg |
| E0667 | Segmental pneumatic appliance for use with pneumatic compressor, full leg |
Provider Responsibilities and Authorization
Prior Authorization Requirement
Preauthorization is required for pneumatic compression devices under this policy; coverage determinations for specific HCPCS codes will follow the referenced NCD or Milliman (MCG) clinical criteria and must be obtained prior to service as required by the plan.
Requesting Coverage Criteria
If you need the coverage criteria or do not have MCG login credentials, contact the plan at the email address provided to request access or the applicable clinical criteria.
- Email for requests and MCG login assistance: umanagement@p3hp.org
- MCG Clinical Criteria and NCD 280.6 are the sources used for coverage determinations depending on HCPCS code.
Definitions
Medical Necessity Determination
External clinical criteria — NCD or MCG by HCPCS code
Medical necessity and coverage for pneumatic compression devices are determined by the external clinical criteria referenced below based on the HCPCS code requested.
ANY of the following
- When the requested HCPCS code is one of E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, or E0673, apply Milliman (MCG) clinical criteria for pneumatic compression devices.
Access to MCG may require login; contact umanagement@p3hp.org if criteria or access are needed.
Documentation Requirements
Provide documentation per NCD/MCG criteria
Documentation must demonstrate medical necessity in accordance with the referenced NCD 280.6 or Milliman (MCG) clinical criteria for the specific HCPCS code when submitting a prior authorization.
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