Pneumatic Compression Devices

Coverage Summary

Scope: Clinical review criteria for coverage and medical necessity of pneumatic compression devices (PCDs) for treatment of lymphedema, chronic venous insufficiency, peripheral arterial disease (PAD), and prevention of postoperative DVT/VTE applicable to Kaiser Permanente Washington members (Medicare and non‑Medicare). Includes coding guidance (HCPCS E0650–E0673 as potentially covered; E0675, E0676, A4600 as not medically necessary) and indications considered medically necessary vs not medically necessary.

Lead-in / background: This policy summarizes the evidence and Medicare policy (National Coverage Determination NCD 280.6) and Noridian LCD history (retired LCD L33829 and article A52488) to guide medical necessity determinations for pneumatic compression devices. Dates: effective 2012-05-01; last review 2026-01-06.

Pneumatic Compression Devices — key facts

Scope summaryClinical review criteria for medical necessity and coverage of pneumatic compression devices for lymphedema, chronic venous insufficiency, PAD, and prevention of postoperative DVT/VTE; includes coding guidance and Medicare/Non‑Medicare applicability

Coverage stanceMixed — some HCPCS (E0650–E0673) may be covered when criteria met; other codes (E0675, E0676, A4600) considered not medically necessary; portable IPC for DVT prophylaxis and IPC for PAD do not meet MTAC criteria

StatusCURRENT — policy effective 2012-05-01; last review 2026-01-06; multiple MPC review dates through 01/06/2026

Key evidence reviewsMTAC reviews: Portable compression devices for post‑op DVT — MTAC conclusion 04/16/2012 (insufficient/mixed evidence); IPC for PAD — MTAC conclusion 02/04/2008 (insufficient evidence)

PayerKaiser Permanente (Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.)

Medical Necessity Criteria

Medicare & Non‑Medicare: Considered Medically Necessary

Considered Medically Necessary when criteria in the applicable policy statements listed above are met

Device is used for treatment of lymphedema or treatment of chronic venous insufficiency of the lower extremity

Refer to applicable Medicare NCD 280.6 and adopted LCD L33829 criteria where appropriate

Clinical documentation supports medical necessity

Request last 6 months of clinical notes from requesting provider/specialist and last 6 months of radiology notes if applicable

Medicare & Non‑Medicare: Considered Not Medically Necessary

The following HCPCS codes/indications are considered not medically necessary

Any of the following: Use of pneumatic compression device for prevention of postoperative deep vein thrombosis (VTE prophylaxis) in the outpatient setting

Coding

Covered HCPCS (when criteria met) - Pneumatic compressor and appliancesHCPCSCovered

E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure
E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure
E0655	Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest
E0660	Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg
E0667	Segmental pneumatic appliance for use with pneumatic compressor, full leg

1–10 of 16

1/2

Not Medically Necessary HCPCS/CodesHCPCSNot Covered

E0675	Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)
E0676	Intermittent limb compression device (includes all accessories), not otherwise specified
A4600	Sleeve for intermittent limb compression device, replacement only, each (used for devices described by E0676)

Provider Actions

Documentation Required

Submit clinical documentation to support medical necessity

When requesting pneumatic compression device (PCD) services, submit documentation to support medical necessity.

Last 6 months of clinical notes and last 6 months of radiology notes if applicable

Prior Authorization

Prior authorization / medical necessity review required

Prior authorization and medical necessity review are required; services must meet applicable Medicare medical necessity determinations.

Services must meet LCD L33829 and NCD 280.6
Verify authorization requirements by plan type via Pre-authorization Code Check

Background & Evidence

Summary of evidence and policy context: Kaiser MTAC reviews concluded that portable compression devices for postoperative DVT prophylaxis do not meet MTAC criteria due to limited, mixed, or insufficient evidence and trial design limitations (trials often compared portable devices plus chemoprophylaxis to chemoprophylaxis alone, lacked head-to-head comparisons with graduated compression stockings, and had potential bias). MTAC also concluded there is insufficient evidence to determine efficacy of IPC for treatment of intermittent claudication or more severe PAD symptoms.

Medicare policy and LCD history: The policy references NCD 280.6 (Pneumatic Compression Devices) and notes Noridian retired Pneumatic Compression Devices LCD L33829 and Local Coverage Article A52488 (effective 11/14/2024), but instructs to continue to use LCD L33829 in addition to NCD 280.6 when determining medical necessity. Medicare determinations have generally not considered pneumatic compression for outpatient VTE prophylaxis (E0676, A4600) medically necessary and note statutory noncoverage for devices used solely for prophylaxis under Social Security Act §1862(a)(1)(A).

Clinical rationale and device distinctions: MTAC and the background evidence emphasize important distinctions between graduated compression stockings (GCS) and intermittent pneumatic compression (IPC) — different mechanisms (constant gradient pressure vs intermittent venous emptying), different device types (standard hospital IPC versus newer lightweight portable battery-powered devices), and variable device characteristics (whole-leg vs calf vs foot cuffs; segmental vs nonsegmental inflation; rapid vs moderate inflation rates) that affect efficacy and especially patient compliance.

Compliance and implementation issues: Trials reported average compliance around ~80% for portable devices but noted adverse effects such as discomfort, pruritus, and sweating; standard IPC devices in hospitals have limitations (size, weight, power reliance) that reduce compliance and therefore may limit real-world efficacy. Policy operationally merged intermittent pneumatic compression criteria into this set and updated coding and revision history per the MPC, while retaining instruction that services still require medical necessity review and documentation (e.g., last 6 months of clinical and radiology notes) when requested.

Medicare Determinations

Name	Number	Type	Effective Date
Pneumatic Compression Devices	280.6	NCD
Pneumatic Compression Devices (retired)	L33829	LCD	2011-11-14
Pneumatic Compression Devices (A52488) (retired)	A52488	Local Coverage Article	2011-11-14

Revision History

06/01/2024policy_revision

MPC approved adoption of the Medicare LCD Pneumatic Compression Devices (L33829) for commercial members; requires 60-day notice and merged Intermittent Pneumatic Compression Device with this criteria set (effective June 1, 2024).

11/14/2024retirement_notice

Noridian retired Pneumatic Compression Devices policies (LCD L33829 and Local Coverage Article A52488); guidance: continue to use LCD L33829 in addition to NCD 280.6 for determining medical necessity.

04/05/2022code_maintenance

Updated applicable HCPCS codes (code list maintenance).