ModifiedKaiser PermanentePolicy N/A

Pneumatic Compression Devices (PCDs) — Clinical Review Criteria

Clinical review criteria governing use of pneumatic compression devices for prevention of deep vein thrombosis (DVT), treatment of lymphedema and chronic venous insufficiency, and intermittent pneumatic compression for peripheral arterial occlusive disease for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyPneumatic Compression Devices (PCDs) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeAdopted LCDcriteria revisionsmerged device criteria

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit last 6 months of relevant clinical and radiology notes when requesting pneumatic compression devices; verify HCPCS-specific authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Policy adopted the Medicare LCD Pneumatic compression devices L33829 for commercial members, effective June 1, 2024, after a 60-day notice.

Added new review criteria for pneumatic devices for Non‑Medicare members with effective date 10/15/2018.

Policy merged Intermittent Pneumatic Compression Device criteria with the pneumatic compression device criteria set.

3 indicationsprimary topic areas

NCD 280.6NCD referenced

E0675, E0676, A4600Not medically necessary codes

NNT = 8

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 Criteria for Pneumatic Compression Devices

Portable compression devices for prevention of post-operative DVT

Summary of evidence-based coverage positions and trial findings informing medical necessity assessments

DVT Prophylaxis (portable devices): Randomized trials compared portable compression devices to chemoprophylaxis; most patients randomized to portable devices also received pharmacologic prophylaxis and in some trials graduated compression stockings. Trials were randomized but unblinded, used varying definitions of major bleeding, and several were manufacturer‑supported. Results showed significantly lower major bleeding rates with portable devices and, in some trials (notably total knee arthroplasty), lower DVT rates when used in combination with LMWH (NNT = 8 in one trial); thromboembolic outcomes were secondary in many studies and equivalence to chemoprophylaxis was not established.

Trials frequently allowed concurrent chemoprophylaxis; average device compliance ~80% in trials.

Intermittent pneumatic compression for peripheral arterial occlusive disease

Intermittent pneumatic compression devices for PAD

IPC for PAD: Devices such as ArtAssist, Flow Medic, and ArterialFlow are FDA‑cleared and apply high pressures via inflatable cuffs to the foot, calf, and/or thigh with proposed mechanisms that augment arterial inflow (venous emptying, increased arteriovenous pressure gradient, endothelial-mediated vasodilation, and collateral stimulation). However, the evidence base consists of small randomized and nonrandomized trials with variable patient populations; overall MTAC concluded evidence is insufficient to determine efficacy for intermittent claudication or more severe PAD and that IPC for this indication does not meet MTAC criteria unless specific medical necessity is documented.

Document prior conservative therapies (exercise program, risk factor control, revascularization) when requesting IPC for PAD.

Evidence-based conclusions — MTAC reviews and policy stance summaries

Evidence conclusions and policy stance from MTAC reviews:

Portable compression devices for DVT prophylaxis after joint arthroplasty or high-risk neurosurgical patients: MTAC reviews of randomized trials concluded that portable compression devices do not meet Kaiser Permanente Medical Technology Assessment Criteria. Trials showed lower major bleeding with devices and some reductions in DVT when devices were used in combination with pharmacologic prophylaxis, but thromboembolic outcomes were secondary, studies were unblinded, definitions varied, and several were manufacturer‑supported.

Key studies include Colwell 2010, Edwards 2008, Gelfer 2006, and Sobieraj‑Teague 2012.

Intermittent pneumatic compression for peripheral arterial occlusive disease (intermittent claudication): MTAC reviews found small RCTs and limited observational data; overall evidence is insufficient to determine efficacy for intermittent claudication or more severe PAD. The policy concludes IPC for PAD does not meet MTAC criteria.

References include Kakkos 2005, Ramaswami 2005, Delis 2005.

For Medicare members, outpatient use of pneumatic compression devices solely for prevention of postoperative venous thromboembolism is governed by Medicare coverage guidance. Per NCD 280.6 and related Medicare policy interpretation, pneumatic compression for outpatient VTE prophylaxis (including HCPCS E0676 and associated sleeve code A4600) has generally been considered statutorily non-covered because devices used solely to prevent disease are excluded under the Social Security Act. Retired Local Coverage Determination L33829 and other CMS resources are cited for determination of medical necessity and review requirements.

Intermittent pneumatic compression (IPC) for the treatment of peripheral arterial occlusive disease (PAD) has been evaluated in small randomized and nonrandomized studies but the evidence is insufficient to establish efficacy for intermittent claudication or more severe PAD. As summarized in the policy, IPC for the PAD indication (HCPCS E0675) has generally not been considered medically necessary in prior Medicare and local coverage guidance unless explicit medical necessity criteria are met and documented.

The Medical Technology Assessment Committee (MTAC) reviewed portable compression devices on 4/16/2012 and concluded that the published trials did not meet Kaiser Permanente MTAC criteria for routine use for prophylaxis. Although trials often compared portable devices (frequently used with chemoprophylaxis or graduated compression stockings) and reported lower major bleeding rates, thromboembolic outcomes were secondary, study designs varied, and some were manufacturer-supported; therefore MTAC determined portable compression devices do not meet the assessment criteria.

The policy lists specific HCPCS codes that are considered not medically necessary. Codes explicitly identified as not medically necessary include E0675 (high‑pressure pneumatic compression device for arterial insufficiency), E0676 (intermittent limb compression device, not otherwise specified), and A4600 (replacement sleeve for an intermittent limb compression device).

Coding: HCPCS and CMS Codes

Mentioned HCPCS and CMS guidanceHCPCS

E0675	Intermittent pneumatic compression device, treatment indication referenced (PAD)
E0676	Pneumatic compression for VTE prophylaxis (not generally considered medically necessary per cited guidance)
E0650	Pneumatic compression device, code range for lymphedema (E0650-E0652 referenced)
E0651	Pneumatic compression device (lymphatic)
E0652	Pneumatic compression device (lymphatic)
A4600	Pneumatic compression device component (referenced with E0676)

Covered HCPCS codes (when criteria met)HCPCSCovered

E0650	Pneumatic compressor_nonsegmental home_mode.
E0651	Pneumatic compressor,_segmental home model without calibrated gradient pressure_.
E0652	Pneumatic compressor,_segmental home model with calibrated gradient pressure.
E0655	E0655 (description not provided in chunk).
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.
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor_full arm.
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor__half.
E0667	E0667 (description not provided in chunk).

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, Prior Authorization, and Documentation

Denial Risk

Medicare non-coverage risk for prophylactic use

Medicare outpatient VTE prophylaxis with pneumatic compression devices (E0676, A4600) is generally considered non-covered/ not medically necessary per NCD 280.6 and retired LCD L33829. Providers should be aware there is a Medicare non-coverage risk for prophylactic use and requests for prophylactic devices for Medicare members may be denied.

Applies to outpatient VTE prophylaxis (E0676, A4600)
Refer to Medicare Benefit Policy Manual Chapter 16 for Services Not Reasonable and Necessary

Documentation Required

Required documentation

Requesters must supply recent clinical and imaging documentation to substantiate medical necessity. Submissions missing required documentation may be returned or denied.

Last 6 months of radiology notes, if applicable

Background and Rationale

Thromboembolic disease, including deep vein thrombosis and pulmonary embolism, is a common postoperative complication—particularly after major joint arthroplasty. Mechanical methods of prophylaxis are used when bleeding risk limits pharmacologic prophylaxis or as adjunctive measures. Mechanical options include graduated compression stockings and intermittent pneumatic compression (IPC), which may be applied to the foot, calf, or whole leg and can inflate uniformly or sequentially. Portable, battery‑powered compression devices were developed to improve ambulatory/home use and compliance compared with traditional hospital IPC systems; randomized trials have evaluated these portable devices often in combination with chemoprophylaxis, with mixed results for thromboembolic outcomes and generally better bleeding profiles when used instead of pharmacologic agents.

Definitions

Lymphedema (primary and secondary forms)

DefinitionAccumulation of tissue fluid due to disorders of the lymphatic system; edema from other causes must be ruled out for Medicare reimbursement of PCDs (E0650–E0652).

Primary lymphedemaCongenital/inherited lymphatic disorder (examples: Milroy's disease, lymphatic aplasia/hypoplasia, lymphedema praecox, lymphedema tarda).

Secondary lymphedemaMore common; caused by another disease or condition (most commonly surgery such as lymph node dissection, radiation therapy, or from chronic venous insufficiency with leakage of fluid into tissues).

Chronic Venous Insufficiency (CVI)

CVI definitionCondition of the lower extremities caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood in the veins.

Clinical signs

Policy Revision History

2018-07-10added_review_criteria

Added new review criteria for pneumatic devices for Non‑Medicare members (effective date 2018-10-15).

2024-01-09adopted_lcd

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

2024-06-01lcd_effective_date