CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Compression Garments (stockings, burn garments, gradient pressure aids) Coverage and Reimbursement

This policy governs coverage and reimbursement for compression garments (including stockings, burn garments, gradient pressure aids and related supplies) for Blue Cross Blue Shield - Rhode Island members; it explains coverage criteria, unit limits, and applicable HCPCS codes for DME providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCompression Garments (stockings, burn garments, gradient pressure aids) Coverage and Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a physician order and dispense from a durable medical equipment provider for coverage; OTC stockings are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8 stockingsmaximum per 12 months

3daytime per body area (6 mo)

2nighttime per body area (24 mo)

A65xx/A66xx/S84xxHCPCS codes listed

Coverage Criteria

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General coverage criteria

Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable durable medical equipment benefits/coverage.

ALL of the following

Compression garments/stockings are covered when ordered by a physician and obtained from a durable medical equipment (DME) provider.
Over the counter (OTC) support hose/stockings/garments (e.g., medical support hose, fabric supports, elastic stockings with no degree of pressure, surgical leggings) are not covered and are member liability.
A member may be dispensed up to 8 compression stockings or 4 pairs per 12 months after the initial dispensed compression garment(s)/stocking(s). See Maximum Units policy for unit limits.
Member-level annual limit; consult benefit booklet for contract-specific limits.

Coverage and limits

Medicare Advantage Plans and Commercial — The following HCPCS code(s) are covered when filed by a DME provider. Note: codes listed are covered but not separately reimbursed when dispensed by a physician office or an institutional provider.

ALL of the following

Covered HCPCS/HCPCS ranges include A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6589, A6593, A6594, A6595, A6596, A6597, A6598, A6599, A6600, A6601, A6602, A6603, A6604, A6605, A6606, A6607, A6608, A6609, A6610, A6611, S8420, S8421, S8422, S8423, S8424, S8425, S8426, S8427, S8428, S8429.
Quantity and frequency limits: a quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months.
Quantity and frequency limits: a quantity of two (2) nighttime garments per body area are allowed once every two (2) years (24 months).
Replacement limited to frequency limitations above: once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.
The RA modifier (replacement of a DME, Orthotic or Prosthetic Item) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged.
RA modifier must be supported by documentation of loss/theft or irreparable damage.

Coding and Quantity Limits

Covered HCPCS codes when filed by DME providersHCPCSCovered

A6501-A6566, A6570-A6611, S8420-S8429

Various custom and ready-made compression burn garments, gradient compression stockings, wraps, supplies and accessories as listed in policy

Gradient compression stocking codesHCPCSCovered

A6530-A6541, A6544-A6556

Gradient compression stockings by location and mmHg ranges

Enumerated HCPCS codes for gradient compression garments and suppliesHCPCSCovered

A6582	Gradient compression gauntlet, each
A6583	Gradient compression wrap with adjustable straps, below knee, 30-50 mm Hg, each
A6606	Gradient compression bandaging supply, padded textile, per linear yard
A6610	Gradient compression stocking, below knee, 18-30 mm hg, custom, each
S8420	Gradient pressure aid (sleeve and glove combination), custom made
S8429	Gradient pressure exterior wrap

inv-06: Pressure thresholds

18-30 mmHgCodes correspond to this compression range (e.g., A6530, A6533, A6539, A6610)

30-40 mmHgCodes correspond to this compression range (e.g., A6531, A6534, A6537)

40 mmHg or greaterCodes correspond to this higher compression range (e.g., A6535, A6541, A6538)

inv-07: daytime quantity limit

Daytime quantity limit3 daytime garments or wraps per body area once every 6 months

Replacement frequency (daytime)Replacement permitted in accordance with the 6-month frequency limitation

ApplicabilityApplies to listed gradient compression garments and wraps by body area

inv-08: nighttime quantity limit

Nighttime quantity limit2 nighttime garments per body area once every 24 months

Replacement frequency (nighttime)Replacement permitted in accordance with the 24-month frequency limitation

RA modifier ruleRA modifier may be used only if garment is lost, stolen, or irreparably damaged

Provider Actions and Billing Rules

Prior Authorization

Prior authorization: Not applicable.

Denial Risk

OTC Exclusion

Over-the-counter (OTC) support hose/stockings/garments (e.g., medical support hose, fabric supports, elastic stockings with no degree of pressure, surgical leggings) are not covered and are member liability.

Billing Rule

Replacement Modifier Rule

Replacement modifier rule: The RA modifier (replacement of a DME, Orthotic or Prosthetic Item) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged. Replacement of garments is subject to the policy frequency limits: once every six (6) months for daytime garments or wraps and once every two (2) years (24 months) for nighttime garments. Quantities allowed: three (3) daytime garments or wraps per body area once every six (6) months; two (2) nighttime garments per body area once every two (2) years.

RA modifier permitted only for items lost, stolen, or irreparably damaged
Daytime garments/wraps: up to 3 per body area every 6 months
Nighttime garments: up to 2 per body area every 24 months
Replacements must follow the stated frequency limits

Definitions

inv-12: Compression garment

DefinitionA typically fitted elastic support garment fabricated to apply varying pressure gradients; includes stockings, sleeves, burn garments and gradient pressure aids.

DME classificationCompression garments are considered Durable Medical Equipment (DME)

Clinical purposeUsed to relieve venous stress, decrease edema, stimulate circulation, and in burn treatment

inv-13: Prescription vs OTC stockings

Prescription (graduated) stockingsGraduated (pressure decreases from ankle up), available in specific pressure grades; require physician order and trained fitter

Over‑the‑counter (OTC) stockingsLower grade, may not be graduated, and are not covered (member liability)

Higher pressuresHigher pressure stockings typically range from 20-30 mmHg to 50+ mmHg and require prescription and trained fitting

inv-14: gradient compression garments and supplies

Covered HCPCS seriesGradient compression garments and supplies are identified by HCPCS codes in the A65xx, A66xx and S84xx series (numerous specific codes listed)

Examples - wraps & gauntletsA6582 (gauntlet), A6583 (below knee wrap 30-50 mm Hg), A6585 (above knee wrap), A6586 (full leg wrap)

Examples - bandaging supplies & stockingsA6594–A6609 (bandaging supplies), A6610 (below knee custom 18-30 mm Hg), S8420–S8429 (gradient pressure aids)