Custom-Fabricated Compression Garments (excluding lymphedema)
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Defines medical necessity and prior authorization requirements for custom compression garments and items on the DC Medicaid Fee Schedule designated as 'Manual Pricing' for MedStar Family Choice DC enrollees (excluding lymphedema covered under a separate policy).
07/25: Updated Director, Clinical Operations; No substantive changes.
07/24: Updated Responsible Parties to include only position titles and not names.
07/22: Updated Responsible Parties and Approved.
Coverage Criteria for Custom Compression Garments
Initial Garment Criteria
Custom compression garments and 'Manual Pricing' items may be considered medically necessary and approved when ALL of the following are met:
Clinical records must support medical necessity and be dated prior to receipt of the garment(s) request.
Replacement Garment Criteria
Replacement Garment Requirements:
Replacement may be approved per these conditions.
This policy specifically excludes lymphedema diagnoses. Coverage and authorization for lymphedema-related compression garments are addressed under Policy 1418.DC; do not use this policy to request or authorize services for lymphedema.
Custom-fabricated compression garments should be reserved for situations where prefabricated or prefabricated custom-fitted garments cannot meet the enrollee’s clinical needs. Prefabricated (ready-made) garments are manufactured for general use but are prescribed and measured to fit an individual, while custom-fabricated (custom-made) garments are individually made for a specific patient. Advances in technology mean that very few patients require fully custom-made items; providers must document why a prefabricated or prefabricated custom-fitted option is unsuitable before requesting custom fabrication.
Provider Requirements, Authorization, and Documentation
Obtain prior authorization for custom and 'Manual Pricing' items
Prior authorization must be obtained for custom compression garments and for items on the DC Medicaid Fee Schedule designated as 'Manual Pricing.' Requests must be forwarded with supporting clinical information in accordance with the MedStar Family Choice DC Prior Authorization Policy.
- Prior authorization is required for custom compression garments and 'Manual Pricing' items.
- Requests must be forwarded along with supporting clinical information per the MedStar Family Choice DC Prior Authorization Policy.
Document step from prefabricated to custom and involve specialty therapy
Before a custom garment is approved, the provider must document why prefabricated (including prefabricated custom-fitted or standard) garments are unsuitable for the enrollee; the enrollee must be under the care of a specialty therapist or chronic edema program and specialty therapy documentation must support the need for custom fabrication.
- Document clear explanation why prefabricated/custom-fitted/standard items cannot be used (a letter alone is insufficient).
- Enrollee must be under care of a specialty therapist or chronic edema program and specialty therapy documentation must be included.
Provide full supporting clinical documentation dated before the request
Submit complete clinical documentation dated prior to the garment request, including evidence of documented severe edema, the specialist’s recommendation explaining why prefabricated garments are insufficient, the amount of compression required, dated measurements, evidence the ordering practitioner personally evaluated the enrollee, and documentation of donning/doffing training and patient education on wear schedule.
- Documented severe edema in the affected extremity.
- Specialist recommendation with explanation why prefabricated garments are unsuitable.
- Amount of compression needed documented by the specialist.
- Dated measurements for the garment(s) and date taken.
- Ordering practitioner’s personal evaluation of the enrollee.
- Documentation of training in donning/doffing and education on wear schedule.
Document need for replacements and when practitioner note suffices
For replacement garments, document that the prior custom compression garment’s integrity cannot be restored (worn out). If the enrollee’s skin integrity and limb size are stable compared with the initial fitting, a practitioner’s note attesting to stability plus an order is sufficient; specialty therapist re-evaluation is not required.
- Documentation that the prior garment cannot be restored (worn out).
- If limb size and skin integrity are stable, include practitioner note attesting to stability and an order (no specialty therapist re-evaluation needed).
Failure to provide required dated clinical records or rationale can trigger denial
Denials may be triggered if clinical records are not dated prior to receipt of the garment request, if there is no documentation explaining why prefabricated garments cannot be used, if severe edema is not documented, or if required measurements, practitioner evaluation, or therapist documentation are missing.
- Clinical records supporting medical necessity must be dated prior to receipt of the garment(s) request.
- Lack of explanation why prefabricated options are unsuitable can trigger denial.
- Absence of documented severe edema, missing measurements, or absence of practitioner/specialty therapist evaluation may trigger denial.
Not obtaining prior authorization may lead to non-coverage
If prior authorization is not obtained for custom compression garments or items designated as 'Manual Pricing' on the DC Medicaid Fee Schedule, the request may result in non-coverage.
- Prior authorization is required; lack of prior authorization may result in non-coverage.
Key Definitions
Background
Compression garments apply external pressure to affected limbs to reduce edema, improve venous hemodynamics, and decrease reflux. Prescription‑grade garments may be either custom-fabricated or prefabricated custom-fitted; because of technological advances, most garments can be prefabricated and only a small subset of patients will require custom fabrication.
Revision History and Policy Changes
Updated Director, Clinical Operations; no substantive clinical changes were made.
Responsible Parties updated to include only position titles rather than individual names.
Updated Responsible Parties and policy marked Approved.
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