CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP022

Pneumatic Compression Devices

Governs billing, coding, reimbursement, and documentation requirements for home-use pneumatic compression durable medical equipment (DME) for Blue Cross Blue Shield of New Mexico members and applicable providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPneumatic Compression Devices

Policy CodePolicy CPCP022

Change TypeMinor edits and code additions

Effective DateOct 31, 2025

Next Review DateN/A

Key ActionVerify member eligibility and prior authorization requirements via the phone number on the member's card or through Availity/preferred vendor before submitting DME claims.

SourceLink

POLICY UPDATE CHANGES

Updated title; grammatical and formatting updates; language under Description section revised; Additional codes added to HCPCS table, E0651, E0657; POS section revised. References updated.

Added HCPCS codes E0651 and E0657 to the HCPCS table.

E0650-E0676Pneumatic compression device codes mentioned

2025-10-31Plan effective date

Home onlyPlace of service

Physician evaluationDocumentation needed

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Coverage criteria and billing rules

Covered when ALL of the following conditions and documentation requirements are met:

ALL of the following

ALL of the following
- Devices covered only for home/place of residence; items used in facility settings are not separately billable.
  Coverage limited to home/place of residence.
ALL of the following
- Documentation criteria in the Plan's Medical Policies (see MED202.060 and DME101.000) must be met for reimbursement.
  See referenced medical policies for detailed clinical criteria.
ALL of the following
- Physician evaluation must document diagnosis and prognosis.
- Physician evaluation must document symptoms and objective findings, including measurements establishing severity of the condition.
- Physician evaluation must document reason the device is required, including treatments which have been tried and failed.
ALL of the following
- Claim must include documentation of appropriate physician oversight and a treatment plan defining the pressure to be used, frequency and duration of use, and ongoing monitoring of use and response to the treatment.
- Documentation must include suitable instruction in the operation of the machine.

ALL of the following

Correct coding and the appendage of an applicable modifier is needed to identify a rental item versus a purchase item for accurate benefit determination and claims processing (e.g., NU for new purchase, RR for rental billed per monthly period, UE for used equipment).
Append appropriate modifier to indicate purchase vs rental vs used equipment.

HCPCS Codes and Coding Rules

HCPCS pneumatic compression device codesHCPCSCovered

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 compression pump.
E0656	Segmental pneumatic compression pump.
E0657	Segmental pneumatic compression pump.
E0660	Non-segmental pneumatic compression pump.
E0665	Non-segmental pneumatic compression pump.
E0666	Non-segmental pneumatic compression pump.
E0667	Segmental pneumatic compression pump.

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Accessory bundling rule

Accessory bundling ruleAccessories billed with E0676 (intermittent limb compression device — includes all accessories) are considered inclusive and will be denied for separate payment when billed with E0676.

Affected accessory codesAccessories billed with E0655–E0673 when submitted with E0676 will be denied as inclusive.

Billing consequenceAccessories that are inclusive to E0676 are ineligible for separate reimbursement and will be denied on claim adjudication.

Provider Action Requirements and Claim Review

Prior Authorization

Prior Authorization / Eligibility

Providers are urged to contact the number on the back of the member's card for specific coverage for DMEPOS and/or check eligibility and benefits through Availity® or a preferred vendor to determine prior authorization requirements. The Plan's Medical Policies and member-specific benefits determine coverage and documentation requirements — this policy language does not constitute plan authorization or an explanation of benefits.

Contact member services (back of card) or check Availity®/vendor portals for prior authorization and benefit details
Verify member eligibility and any plan-specific prior authorization rules before billing

Documentation Required

Documentation and Claim Review

The Plan reserves the right to request supporting documentation to substantiate medical necessity, correct coding, and appropriate billing (rental vs purchase). Failure to supply requested documentation or to adhere to coding and billing policies may impact claims processing and reimbursement.

Plan may request medical records, justification for device selection, proof of home/place of residence use, and rental vs purchase documentation
Noncompliance with documentation requests can lead to claim denial, delayed payment, or recoupment

Denial Risk

Accessory Bundling and Denial

When HCPCS code E0676 (intermittent limb compression device — includes all accessories) is billed together with accessories reported using codes E0655–E0673, the accessories are considered inclusive to E0676 and will be denied as separate payable items.

If E0676 is billed, do not separately bill accessories using E0655–E0673 (these will be denied as inclusive)
Review HCPCS coding guidance to determine whether to bill E0676 or the individual device/accessory codes based on the service provided

Definitions

Pneumatic compression device

DefinitionPneumatic compression device consists of an inflatable garment for the arm, leg, trunk or chest and an electrical pneumatic pump that fills the garment with compressed air; the garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.

ComponentsInflatable garment (sleeve/appliance) and electrical pneumatic pump.

FunctionIntermittent inflation/deflation to apply external pressure for therapeutic compression.

Segmented compressor

DefinitionSegmented compressor is a device with multiple outflow ports on the compressor which lead to distinct segments on the appliance that inflate sequentially.

Distinct segmentsMultiple outflow ports correspond to separate sleeve segments that are inflated in sequence.

Related HCPCSSegmental pneumatic compression pumps are represented in HCPCS code ranges including E0656, E0657, E0667–E0669, E0670 and segmental appliance codes E0671–E0673.

Venous thromboembolism (VTE)

DefinitionVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) — formation of a blood clot in a deep vein — and pulmonary embolism (PE) — blockage of a lung artery by material that traveled through the bloodstream.

Clinical relevanceVTE is a complication associated with major surgeries and can result in significant morbidity and mortality.

Prevention contextSome pneumatic compression devices (e.g., E0676) are indicated for DVT prophylaxis in the context of deep vein thrombosis prevention.