CurrentBlue Cross Blue Shield - TexasPolicy CPCP022

Pneumatic Compression Devices

Provides billing, coding, modifier, place-of-service, documentation, and reimbursement guidance for durable medical equipment pneumatic compression devices for home use and identifies related medical policies and codes for Blue Cross Blue Shield of Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPneumatic Compression Devices

Policy CodePolicy CPCP022

Change TypeNon-clinical clarifications

Effective DateOct 31, 2025

Next Review DateN/A

Key ActionVerify member eligibility and prior authorization requirements via the phone number on the back of the member card, Availity, or preferred vendor before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Language under Description section revised; Additional codes added to HCPCS table, E0651, E0657; POS section revised.

home use onlyDME coverage setting restriction

E0650-E0676HCPCS codes listed

Physician evaluationDocumentation required

DME101.000, MED202.060Related policies

Coverage and Billing Criteria

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPneumatic Compression Devices

Policy CodePolicy CPCP022

Change TypeNon-clinical clarifications

Effective DateOct 31, 2025

Next Review DateN/A

Key ActionVerify member eligibility and prior authorization requirements via the phone number on the back of the member card, Availity, or preferred vendor before submitting claims.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and billing criteria for pneumatic compression devices

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Covered only for home/place of residence; facility or office use is not separately billable and is considered part of the facility/office charge.
ALL of the following
- Reimbursement requires that documentation criteria outlined in the Plan's Medical Policies (for example, DME101.000 and MED202.060) are met.
ALL of the following
- Physician oversight evaluation, instruction in operation, and a treatment plan defining pressure, frequency and duration with ongoing monitoring must be submitted with the claim or upon request.
ALL of the following
- Evaluation must include diagnosis/prognosis, symptoms and objective findings (measurements establishing severity), reason the device is required, treatments tried and failed, and a physician order present in the record.
ALL of the following
- Providers should verify member-specific coverage and prior authorization requirements by calling the number on the back of the member's card or checking eligibility/benefits through Availity or a preferred vendor.

ALL of the following

Correct coding and use of applicable modifiers is required to identify rental versus purchase for benefit determination and claims processing (see related modifier reference policy).

ALL of the following

Accessories billed with an all-inclusive code (e.g., E0676) are considered inclusive and are ineligible for separate payment.

ALL of the following

The plan reserves the right to request supporting documentation; plan documents or provider contracts govern if there is a conflict with this policy. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

HCPCS Codes and Coding Guidance

HCPCS codes for pneumatic compression devicesHCPCS

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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1/2

Accessories bundled with E0676

Bundling ruleWhen codes E0655-E0673 are billed with E0676 (all‑inclusive intermittent limb compression device), the accessories are considered inclusive to E0676 and are ineligible for separate payment.

Affected codes (accessories range)E0655 through E0673 are considered accessories when billed with E0676 and will be denied as separate payment.

All‑inclusive codeE0676 is defined as 'Intermittent limb compression device, includes all accessories.'

Reimbursement impactAccessories billed with E0676 will be denied as inclusive and not reimbursed separately.

Prior Authorization, Verification, and Provider Responsibilities

Prior Authorization

Verify benefits and prior authorization via member services or Availity/preferred vendor

Contact the telephone number on the back of the member's card or verify eligibility and benefits through Availity® or a preferred vendor to determine member-specific coverage and whether prior authorization is required for DME pneumatic compression devices.

Use member services/back-of-card phone for plan-specific coverage details for DME, prosthetics, orthotics, and supplies.
Check eligibility/benefits via Availity® or the plan’s preferred vendor to determine prior authorization requirements or plan-specific rules based on DME costs.

Definitions

Pneumatic compression device and related device types

Pneumatic compression deviceAn inflatable garment for the arm, leg, trunk or chest plus an electrical pneumatic pump that intermittently inflates and deflates; cycle times and pressures vary between devices.

Non‑segmented pneumatic compressorDevice with a single outflow port; air is transmitted to a sleeve/appliance that may have multiple compartments or segments.

Segmented compressorCompressor with multiple outflow ports that lead to distinct segments on the appliance which inflate sequentially.

Segmented device with calibrated gradient pressureDevice with a manual control on at least three outflow ports allowing individually determined pressure to each segment.

Segmented device without calibrated gradient pressureDevice in which the same pressure is present in each segment or a predetermined gradient exists but pressures cannot be individually adjusted; pressure set by a single control on the distal segment.

Segmental gradient pressure pneumatic applianceAppliance/sleeve used with a non‑segmental compressor that achieves a pressure gradient through tubing and/or air chamber design.

Venous thromboembolism (VTE)

Venous thromboembolism (VTE)VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE).

Deep vein thrombosis (DVT)Formation of a blood clot in a deep vein.

Pulmonary embolism (PE)Blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream.

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