Prior authorization required for listed HCPCS codes

Prior authorization or medical necessity review is required per the member’s plan for devices billed with HCPCS codes E0650, E0651, E0652, E0656, E0657, and E0660; listing these codes does not guarantee reimbursement.

• Applicable HCPCS codes: E0650, E0651, E0652, E0656, E0657, E0660

Use only after conservative therapies exhausted

Pneumatic compression devices for the chest/trunk/abdomen are considered a treatment of last resort and may only be used after more conservative measures have been tried and found inadequate.

• Examples of conservative treatments to try first: elevation and custom fabricated gradient pressure stockings or sleeves
• Segmented device with manual chamber control (E0652) permitted only when unique patient characteristics are documented

Submit full medical records; letters alone often insufficient

Provide complete medical records when requested to support medical necessity determinations; letters of support alone are often insufficient unless they include all specific information needed by the Plan.

• Include documentation of conservative therapy attempts and outcomes
• Document failure of extremity pump/appliance therapy and any unique patient characteristics (eg, scarring, sensitive skin, contracture) that justify segmented/manual-control devices

Investigational uses — denial risk for trunk/chest and head/neck

Use of lymphedema pumps to treat the trunk or chest in many patients and use of pumps applied to the head and neck are considered investigational and may be denied unless the trunk/chest strict coverage criteria are met.

• Head and neck applications are investigational and not approved
• Trunk/chest treatment is investigational except when all coverage criteria (lymphedema beyond extremities, failed conservative therapy, failed extremity pump/appliance therapy) are met

Document failure of conservative therapy before requesting trunk/chest devices

Coverage for trunk/chest pneumatic compression devices requires documented failure of conservative therapies and failure of lymphedema pump/appliance therapy to the upper and lower extremities; absence of such documentation may result in denial.

• Policy criteria: lymphedema beyond the upper and lower extremities; failed conservative therapy; failed therapy with lymphedema pumps/appliances to the extremities only
• Devices are a treatment of last resort—must show conservative measures tried and inadequate

Supply complete medical records supporting conservative therapy failure and need for segmented/manual-control device

When requested, provide full medical records documenting attempts at conservative therapies, failure of prior extremity pump/appliance therapy, and documentation of any unique patient characteristics that justify a segmented/manual-control device (E0652).

• Document specific conservative treatments tried and their outcomes (e.g., elevation, custom gradient stockings/sleeves).
• Document failure of prior lymphedema pump/appliance therapy to the upper and lower extremities.
• If requesting E0652, include documentation of unique characteristics (for example: significant scarring, sensitive skin, contracture) and the need for specified pressure to a localized area.