Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
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This policy governs coverage criteria, clinical guidance, and coding for home-use pneumatic compression pumps for treatment of lymphedema and venous ulcers for Blue Cross Blue Shield of North Carolina members and providers.
Coverage criteria were moved from Policy Guidelines into a When Pneumatic Compression Pumps are covered section and initial coverage criteria were specified (confirmed diagnosis, functional impairment, failure of a four-week trial of conservative therapies, demonstrated compliance).
Policy statements updated to clarify investigational status for pumps applied to head and neck and to the trunk/chest (with later clarifications expanding conditions where chest/trunk application may be considered medically necessary when additional criteria met).
HCPCS codes E0658 and E0659 are scheduled to be added to the Billing/Coding section effective 10/01/2025.
When Pneumatic Compression Pumps Are Covered
Initial coverage (limb)
Covered when ALL of the following are met:
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Device-specific and anatomical-site criteria
Covered device hierarchy and conditions:
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Continuation therapy
Continued use:
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Initial Therapy
Initial coverage — devices are eligible when ALL of the following criteria are met:
Device-specific exception
Segmented/manual-control device exception
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The following uses are not supported by evidence and are therefore investigational or not medically necessary: the application of lymphedema pneumatic compression pumps to the head and neck is considered investigational, and the use of pneumatic compression pumps to treat venous ulcers is considered investigational. Additionally, the use of active cooling devices in combination with sequential or intermittent pneumatic compression is considered not medically necessary for all indications, including postoperative care.
Except for the specific scenarios described elsewhere in this policy, single-compartment and multichamber compression pumps are considered investigational. Historical statements restricted trunk/chest and head/neck application as investigational; more recent policy updates introduce limited coverage for chest/trunk applications only when the policy’s specific when-covered criteria (including failure of conservative measures and, when applicable, inadequate response to limb-only nonprogrammable therapy) are met.
Active cooling devices used together with sequential or intermittent pneumatic compression are explicitly addressed: such combined use is considered not medically necessary for all indications. This includes use in postoperative care and other settings where cooling is applied concurrently with pneumatic compression.
The policy restates that active cooling devices used with sequential or intermittent pneumatic compression are not medically necessary for any indication. This not-medically-necessary determination applies broadly, including postoperative care, and was added into the When It Is Not Covered section of the policy.
Billing and HCPCS Codes
| E0652 | Segmented pneumatic compression device with manual control of the pressure in each chamber (referenced as medically necessary only with unique characteristics) |
| E0656 | HCPCS code listed in history (added Jan 1, 2009) |
| E0657 | HCPCS code listed in history (added Jan 1, 2009) |
| E0670 | HCPCS code added to Billing/Coding/Physician Documentation Information Section |
| E0675 | HCPCS code added to Billing/Coding/Physician Documentation Information Section |
| E0658 | HCPCS code added effective 10/01/2025 |
| E0659 | HCPCS code added effective 10/01/2025 |
Requirements for Prescribers and Suppliers
Physician prescription and check member certificate for prior authorization
A physician prescription is required for rental or purchase of lymphedema/pneumatic compression pumps; providers must review the member certificate to determine whether prior approval/preauthorization is required and whether the DME supplier meets Plan credentialing requirements.
- Physician prescription required for rental or purchase to be eligible for coverage.
- Review individual member certificate for prior approval/preauthorization requirements.
- DME supplier must meet Plan eligibility/credentialing requirements for reimbursement.
Prior authorization requires prescription and When Covered evidence
Prior authorization (when required by the member's certificate) must include a physician prescription and documentation that the request meets the When Pneumatic Compression Pumps are covered criteria (confirmed primary or secondary lymphedema, associated functional impairment, failed four-week trial of conservative therapies, and demonstrated compliance with prior treatments).
- Include physician prescription with the request.
- Provide evidence of confirmed diagnosis, functional impairment, 4‑week conservative therapy failure, and patient compliance.
Step therapy — pumps only after conservative therapies fail
Pneumatic compression pumps are considered a treatment of last resort and should be used only after conservative therapies (elevation, exercise, compression garments/bandaging, manual lymphatic drainage) have been tried and found inadequate.
- Pumps are covered only after more conservative measures have failed.
- Conservative measures include elevation, exercise, massage/manual lymphatic drainage, and appropriate compression bandage systems or garments.
Conservative therapy trial — 4‑week trial required
Policy requires documentation of a trial of conservative medical therapies for four weeks before pneumatic compression pump coverage will be considered; examples include elevation of the limb, exercise, massage/manual lymphatic drainage, and use of an appropriate compression bandage system or compression garment.
- Document start and end dates of the four‑week conservative therapy trial.
- Specify which conservative modalities were used (e.g., elevation, exercise, massage, compression bandage/garment).
Clinical effectiveness — medical record requests and objective measurements
BCBSNC may request medical records demonstrating clinical effectiveness for continued coverage; documentation should include objective pre- and post-treatment measurements showing decreased edema and/or documented improvement in functional capacity.
- Provide pre- and post-treatment limb measurements and functional status assessments.
- Letters of support are not sufficient unless they include all specific clinical information needed for medical necessity determination.
Required documentation with prescription for rental/purchase
A physician prescription is required for rental or purchase and documentation must include confirmed diagnosis, evidence of functional impairment, documentation of a failed four‑week conservative therapy trial, and demonstration of patient compliance with prior recommended treatments.
- Include confirmed primary or secondary lymphedema diagnosis in documentation.
- Document how lymphedema causes functional impairment (e.g., activities of daily living).
- Document dates and modalities of the 4‑week conservative therapy trial and outcomes.
- Document patient compliance with prior recommended medical treatments.
Investigational / not medically necessary uses — avoid on requests
Uses considered investigational or not medically necessary must be avoided on authorization requests; specifically, pumps applied to the head and neck, pumps used to treat venous ulcers, and uses outside the specified When Covered criteria are flagged as investigational or not medically necessary and may be denied.
- Do not request coverage for pumps applied to the head and neck — policy states this use is investigational.
- Do not submit requests for pneumatic compression pumps to treat venous ulcers — policy states this use is investigational.
- Requests for indications outside the When Covered criteria may be considered investigational or not medically necessary.
Denial risk if coverage criteria documentation is missing
Requests lacking required coverage criteria documentation may be denied; specifically, absence of a confirmed lymphedema diagnosis, no documentation of associated functional impairment, no evidence of a failed four‑week conservative therapy trial, or lack of documented patient compliance are grounds for denial.
- Ensure the request includes confirmed diagnosis of primary or secondary lymphedema.
- Include documentation of functional impairment attributable to lymphedema.
- Provide clear evidence of a failed 4‑week trial of conservative therapies.
- Document patient compliance with prior recommended treatments.
DME Medical Necessity Requirements
DME eligibility
DME medical necessity requirements mirror clinical criteria:
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Initial DME medical necessity
Supplier, Rental, and Purchase Rules
| Equipment | Rental / Purchase Rule | Notes |
|---|---|---|
| Lymphedema pumps / sequential pneumatic compression devices | ||
| Rent for the first two months to establish effectiveness and patient compliance | ||
| A physician prescription is required to rent or purchase; review the individual certificate for prior authorization and DME supplier credentialing requirements as defined by the Plan |
| Item | Rule | Supplier / Documentation Requirements |
|---|---|---|
| Pneumatic compression pumps (general) | ||
| Rental recommended for initial 2 months; purchase allowed where applicable but requires physician prescription | ||
| DME supplier must meet Plan eligibility/credentialing; physician prescription required; review member certificate for prior authorization requirements |
Medical Records and Documentation Requirements
Medical records and objective pre/post measurements may be requested
BCBSNC may request medical records to determine medical necessity for initial or continued coverage; objective pre- and post-treatment measurements or documented functional improvement are required for continued eligibility and letters alone are insufficient unless complete clinical details are included.
- Include measurement data (pre/post) and functional status notes when submitting records.
Prescription required; check prior approval and supplier credentialing
A physician prescription is required for rental or purchase of pneumatic compression pumps; verify whether prior approval is required per the member certificate and ensure the DME supplier meets Plan credentialing rules for reimbursement.
- Review the member certificate for prior approval/preauthorization requirements.
Include physician prescription and clinical documentation meeting When Covered criteria
Provide a physician prescription and clinical documentation that the request meets the 'When Covered' criteria (confirmed diagnosis of primary or secondary lymphedema, associated functional impairment, failed four‑week conservative trial, and demonstrated compliance) when submitting requests for rental or purchase.
Services and Uses Not Covered
Items and uses that are specifically excluded from coverage include: pneumatic compression pumps applied to the head and neck for lymphedema and pneumatic compression pumps used to treat venous ulcers (both considered investigational), and the combined use of pneumatic compression with active cooling devices (considered not medically necessary).
The policy clarifies investigational uses: historically, applications of pumps to the trunk/chest and to the head/neck were listed as investigational. The document maintains that single-compartment and multichamber pumps are investigational except in the limited situations explicitly described as covered. Updates have added narrow, conditional coverage for some chest/trunk applications when the specified criteria are met, but uses outside those defined conditions remain investigational.
Clinical Background
Lymphedema is an accumulation of lymphatic fluid due to partial or complete obstruction of lymphatic flow and may be primary or secondary in origin. Initial management is conservative and includes elevation, exercise, compression bandaging or garments, manual lymphatic drainage, and complete decongestive therapy. Pneumatic compression pumps deliver intermittent or sequential external pressure via inflatable cuffs to mobilize lymphatic fluid; devices are available as single-chamber, multichamber nonprogrammable, or programmable systems, and a segmented/manual-control device (HCPCS E0652) may be considered when unique patient characteristics (for example, significant scarring, contracture, or highly sensitive skin) prevent satisfactory treatment with nonsegmented devices.
Device Definitions and HCPCS Mapping
Replacement and Repair
Policy Revision History and Updates
References updated and related policies updated (includes Surgical Treatment for Lipedema); Policy Guidelines updated after Specialty Matched Consultant Advisory Panel and Medical Director reviews in April 2026.
HCPCS codes E0658 and E0659 added to the Billing/Coding section effective 10/01/2025.
References updated and related policies updated to include Surgical Treatment for Lymphedema; Policy Guidelines updated after Specialty Matched Consultant Advisory Panel and Medical Director reviews in April 2025.
Coverage criteria were moved from Policy Guidelines into the 'When Pneumatic Compression Pumps are covered' section and initial coverage criteria were specified (confirmed diagnosis, functional impairment, failure of a four-week trial of conservative therapies, demonstrated compliance).
Policy statement regarding trunk/chest application of lymphedema pumps clarified to apply regardless of involvement of upper and lower limbs; intent unchanged.
Policy statement added that use of lymphedema pumps applied to the head and neck to treat lymphedema is considered investigational (notification 2/8/2022; effective 4/19/2022).
Title changed to Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers; statements added that trunk/chest application and use for venous ulcers are investigational (policy effective 2/26/2013).
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