CurrentKaiser PermanentePolicy N/A

Stockings/Sleeves (gradient compression garments and related supplies)

Clinical review criteria for medical necessity and coding of compression garments, stockings, sleeves, burn compression garments, surgical dressing compression garments, and related bandaging supplies for Kaiser Foundation Health Plan of Washington members.

Policy Summary

PayerKaiser Permanente

PolicyStockings/Sleeves (gradient compression garments and related supplies)

Policy CodePolicy N/A

Change TypeCoding additions and updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the last 12 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added new HCPC codes for Stockings/Sleeves, effective 1/1/2024.

Removed deleted code L8010.

Added applicable codes A6515-A6519 & A6611 effective 4/1/2025.

Updated coding section with new applicable codes effective 1/1/2024 and description updates.

Added Medicare coverage article for External Breast Prostheses addressing mastectomy sleeve non-coverage.

~120+HCPCS A- and A65xx codes listed

2 pairs/yearReplacement recommendation

18-20 mmHgOTC threshold

Medicare-specificMedicare-required diagnoses

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Coverage and Medical Necessity Criteria

General Medical Necessity

Considered Medically Necessary when ALL of the following are met:

General medical necessity: Documentation supports medical necessity per applicable policy statements; provider must supply requested clinical notes; coverage is determined per member contract and applicable Medicare/MCG guidelines.

Document reference: 'Considered Medically Necessary when criteria in the applicable policy statements listed above are met.'

Mastectomy sleeve items are identified in this policy as non-covered in accordance with Medicare guidance on External Breast Prostheses. The policy was updated to reference the Medicare coverage article addressing External Breast Prostheses which specifically notes the non-coverage of mastectomy sleeves; this reference was added to the Stockings/Sleeves revision history on 07/20/2023. Providers should follow the Medicare guidance when assessing coverage for mastectomy sleeve products for applicable members and verify member-specific benefits.

Elastic stockings that provide approximately 18–20 mmHg of compression or less are generally available over the counter and are not typically subject to prescription-based coverage rules. For non‑Medicare members, Kaiser Permanente uses the MCG guideline for medical necessity determinations and recognizes that these low‑pressure stockings are commonly OTC unless a plan or clinical circumstance specifies otherwise.

HCPCS / ICD Coding

Compression Burn GarmentsHCPCSCovered

A6501	Compression burn garment, bodysuit (head to foot), custom fabricated.
A6502	Compression burn garment, chin strap, custom fabricated.
A6503	Compression burn garment, facial hood, custom fabricated.
A6504	Compression burn garment, glove to wrist, custom fabricated.
A6505	Compression burn garment, glove to elbow, custom fabricated.
A6506	Compression burn garment, glove to axilla, custom fabricated.
A6507	Compression burn garment, foot to knee length, custom fabricated.
A6508	Compression burn garment, foot to thigh length, custom fabricated.
A6509	Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated.
A6510	Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated.

1–10 of 13

1/2

Surgical Dressing Compression GarmentsHCPCSCovered

A6531	Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each.
A6532	Gradient compression stocking, below knee, 40-50 mmhg, used as a surgical dressing, each.
A6545	Gradient compression wrap, non-elastic, below knee, 30-50 mmhg, used as a surgical dressing, each.

Compression Garments (daytime)HCPCSCovered

A6530	Gradient compression stocking, below knee, 18-30 mmhg, each.
A6533	Gradient compression stocking, thigh length, 18-30 mmhg, each.
A6534	Gradient compression stocking, thigh length, 30-40 mmhg, each.
A6535	Gradient compression stocking, thigh length, 40 mmhg or greater, each.
A6536	Gradient compression stocking, full length/chap style, 18-30 mmhg, each.
A6537	Gradient compression stocking, full length/chap style, 30-40 mmhg, each.
A6538	Gradient compression stocking, full length/chap style, 40 mmhg or greater, each.
A6539	Gradient compression stocking, waist length, 18-30 mmhg, each.
A6540	Gradient compression stocking, waist length, 30-40 mmhg, each.
A6541	Gradient compression stocking, waist length, 40 mmhg or greater, each.

1–10 of 12

1/2

Stockings/Sleeves and related supplies (custom and non-custom)HCPCSCovered

A6515	Gradient compression wrap with adjustable straps, full leg, each, custom.
A6516	Gradient compression wrap with adjustable straps, foot, each, custom.
A6517	Gradient compression wrap with adjustable straps, below knee, each, custom.
A6518	Gradient compression wrap with adjustable straps, arm, each, custom.
A6519	Gradient compression garment, not otherwise specified, for nighttime use, each.
A6611	Gradient compression wrap with adjustable straps, above knee, each, custom.
A6520	Gradient compression garment, glove, padded, for nighttime use, each.
A6521	Gradient compression garment, glove, padded, for nighttime use, custom, each.
A6522	Gradient compression garment, arm, padded, for nighttime use, each.
A6523	Gradient compression garment, arm, padded, for nighttime use, custom, each.

1–10 of 72

1/8

Medicare-required diagnoses for lymphedema compression treatmentICD-10

I89.0	Lymphedema
I97.2	Postprocedural lymphedema
I97.89	Other postprocedural complications and disorders of lymphatic system
Q82.0	Epidermal nevus (congenital) — included here per Medicare LCD requirement for certain lymphedema items

Compression pressure thresholds

OTC elastic stockingsApproximately 18-20 mmHg (generally available over the counter)

Listed garment range — low compression18–30 mmHg (multiple HCPCS listings for below-knee, thigh, full length, waist length)

Listed garment range — moderate compression30–40 mmHg (multiple HCPCS listings for thigh, full length, waist length and below-knee)

Listed garment range — high compression40 mmHg or greater (HCPCS listings for thigh, full length, waist length, and below-knee variants)

Surgical dressing/other specified rangesSurgical dressing garments include ranges such as 30–50 mmHg per surgical dressing code group

Provider Responsibilities & Prior Authorization

Prior Authorization

Pre-authorization code verification

Verify authorization requirements for the specific HCPCS code(s) and the member's plan using the Pre-authorization Code Check prior to ordering or billing.

Pre-authorization requirements vary by HCPCS code and plan type; confirm per-code requirements.

Step Therapy

OTC vs prescription compression

Recognize that elastic stockings of approximately 18–20 mmHg or less are generally available over the counter and do not typically require a physician prescription.

Higher degrees of compression (greater than ~18–20 mmHg) generally require a physician's prescription and are subject to coverage criteria.

Documentation Required

Required clinical documentation

Include the last 12 months of clinical notes from the requesting provider and/or specialist with the request to support medical necessity.

Clinical notes should document the clinical indication and any prior conservative treatments or relevant findings used to justify the request.

Denial Risk

Risk of denial for missing clinical notes

Failure to submit the last 12 months of clinical notes from the requesting provider and/or specialist may result in denial for lack of documentation to support medical necessity.

Ensure complete submission of requested records to avoid administrative denials.

DME Medical Necessity

Covered when criteria in the applicable policy statements are met

Applicability: Garment or supply corresponds to a clinical indication supported by documentation and meets any diagnosis-specific requirements (e.g., Medicare LCD for lymphedema requires specific ICD-10 codes).

See Medicare and MCG references in document.

Product-group examples: Applies to HCPCS-coded items in the policy, including Compression Burn Garments, Surgical Dressing Compression Garments, daytime Compression Garments, and Stockings/Sleeves and related supplies (custom and non-custom).

See HCPCS groups listed in policy.

Documentation requirement: Request must be supported by the last 12 months of clinical notes from the requesting provider and/or specialist to demonstrate medical necessity.

Failure to submit required clinical notes may risk denial for lack of documentation.

Examples of HCPCS-coded items referenced: See specific HCPCS listings in policy (examples): A6530, A6533–A6539, A6540–A6541, A6544, A6549 (daytime garments); A6531–A6532, A6545 (surgical dressing garments); A6501–A6513 (compression burn garments); A6515–A6611 and A6520–A6610 (stockings/sleeves and supplies).

Verify authorization requirements per code and plan using Pre-authorization Code Check.

Rental, Purchase, and Plan-specific Rules

HCPCS Code	Description	Coverage
A6581	Gradient compression glove, each.	Covered
A6582	Gradient compression gauntlet, each.	Covered
A6583	Gradient compression wrap with adjustable straps, below knee, each.	Covered
A6584	Gradient compression wrap with adjustable straps, not otherwise specified.	Covered
A6585	Gradient compression wrap with adjustable straps, above knee, each.	Covered
A6586	Gradient compression wrap with adjustable straps, full leg, each.	Covered
A6587	Gradient compression wrap with adjustable straps, foot, each.	Covered
A6588	Gradient compression wrap with adjustable straps, arm, each.	Covered
A6589	Gradient pressure wrap with adjustable straps, bra, each.	Covered
A6593	Accessory for gradient compression garment or wrap, not otherwise specified.	Covered
A6594	Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each.	Covered
A6595	Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each.	Covered
A6596	Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each.	Covered
A6597	Gradient compression bandage roll, elastic long stretch, per linear yard, any width, each.	Covered
A6598	Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each.	Covered
A6599	Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each.	Covered
A6600	Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each.	Covered
A6601	Gradient compression bandaging supply, high density foam pad, any size or shape, each.	Covered
A6602	Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each.	Covered

Definitions

Compression garments — definition and properties

DefinitionElastic garments used to promote venous or lymphatic circulation; worn on legs to help prevent DVT and reduce edema

Degrees of compressionAvailable in varying degrees (examples in HCPCS: 18–30 mmHg, 30–40 mmHg, 40 mmHg or greater)

Clinical usesUsed for venous and lymphatic circulation support, edema reduction, prevention of deep vein thrombosis, and treatment/prevention of venous ulcers

Prescription requirementHigher degrees of compression typically require a physician's prescription

Elastic stockings (OTC)

OTC pressure rangeGenerally 18–20 mmHg or less; commonly available over the counter

Coverage implicationOTC elastic stockings (≈18–20 mmHg or less) are not subject to prescription rules unless specified by plan or clinician

MCG referenceKaiser Permanente uses MCG Graduated Compression Stockings/Sleeves criteria for medical necessity determinations for non‑Medicare members

OpenPayer

Stockings/Sleeves (gradient compression garments and related supplies)

Coverage and Medical Necessity Criteria

HCPCS / ICD Coding

Provider Responsibilities & Prior Authorization

DME Medical Necessity

Rental, Purchase, and Plan-specific Rules

Replacement Frequency

Required Clinical Documentation

Background and Clinical Context

Definitions

Not Covered Items