Compression Garments and Stockings Coverage Criteria
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This policy governs coverage and payment for compression garments and stockings provided as durable medical equipment to Medicare Advantage and commercial members of Blue Cross Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Coverage Criteria
Covered when ALL of the following are met
Pre-made garments are acceptable unless a custom gradient pressure garment is required (custom orders may take 6–8 weeks).
Over-the-counter (OTC) support hose, stockings, and garments that are non-graduated or provide no measurable degree of compression are not covered and are the member's financial responsibility. Examples include medical support hose, fabric supports, elastic stockings with no degree of pressure, and surgical leggings. Claims for these OTC items billed as durable medical equipment may be denied.
Coding and Prescription Details
Provider Actions and Billing Impact
Prior Authorization
Prior authorization is not applicable for this policy.
Step Therapy
No step therapy requirements are specified for compression garments/stockings under this policy.
Order and Fitting Requirement
A physician order is required and compression stockings/garments must be fitted and measured by a specially trained individual. Prescription (graduated) stockings — especially higher-pressure garments (typically 20–30 mmHg up to 50+ mmHg) — require a prescription and a trained fitter. Pre-made prescription-grade stockings are available; custom-made garments are rarely needed unless the required pressure gradient cannot be achieved with pre-made items. Allow 6–8 weeks for custom orders when applicable.
- Physician order required
- Fitting/measuring by specially trained individual required
- Higher-pressure (20–30 mmHg to 50+ mmHg) stockings require prescription and trained fitter
- Custom-made orders may take 6–8 weeks
OTC Items Not Covered
Over-the-counter (OTC) support hose/stockings/garments (for example, medical support hose, fabric supports, elastic stockings with no degree of pressure, surgical leggings) are not covered and are member liability. OTC items are lower-grade, may not be graduated, and should not be billed as covered DME.
- OTC non-graduated items not covered — member liability
- Do not bill OTC support hose/stockings/garments as covered DME
Background
Compression garments (also called stockings, sleeves, burn garments, or gradient pressure garments) are fitted elastic support garments designed to apply a controlled pressure gradient to a body area. Their mechanism of action is to improve venous hemodynamics, reduce edema, and support circulation; they are also used in burn care. Coverage requires that the garment be ordered by a physician and obtained from a durable medical equipment (DME) provider. Prescription-grade, graduated compression typically requires measurement and fitting by a trained individual and may be provided as pre-made or custom garments (custom orders can take several weeks).
Definitions
Medical Necessity Criteria
inv-12: DME Medical Necessity — Medical necessity for coverage requires:
Medical necessity for coverage requires:
Pre-made compression garments are acceptable for most needs; custom garments are covered only when the required degree of gradient pressure cannot be met with pre-made items (custom orders may take 6–8 weeks).
Rental and Purchase Rules
| Item | Rental or Purchase Rule |
|---|---|
| Compression garments/stockings (pre-made) | |
| Purchase — Most compression garments are DME and supplied as purchased items; pre-made garments are acceptable and are provided by a DME supplier. | |
| Compression garments requiring custom gradient pressure | |
| Purchase — Custom-made garments are provided when the required degree of gradient pressure cannot be met with pre-made items (custom orders may take 6–8 weeks). |
Replacement and Quantity Limits
Documentation Requirements
Physician order and fitter measurement documentation required
Document a physician order and evidence that fitting/measuring was performed by a specially trained individual; include a prescription when higher-pressure graduated stockings are provided.
- Maintain the physician order in the medical record.
- Document that a specially trained individual performed fitting/measuring when required.
- Include the prescription specifying pressure grade for higher-pressure stockings (typically 20-30 mmHg to 50+ mmHg).
Not Covered Items
The following items are NOT COVERED: over-the-counter support hose, stockings, and garments that are non-graduated or provide no degree of compression. These OTC products are not equivalent to prescription, graduated compression garments and are the member's liability when purchased.
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