CurrentMedStar Family Choice, MarylandPolicy 1422

Custom Compression Garments for Diagnoses Excluding Lymphedema

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Coverage criteria for authorizing custom-fabricated compression garments and Maryland Medicaid Fee Schedule garments designated as “I/C” for members with non-lymphedema diagnoses.

Policy Summary

PayerMedStar Family Choice, Maryland

PolicyCustom Compression Garments for Diagnoses Excluding Lymphedema

Policy CodePolicy 1422

Change TypeMaterial update

Effective DateJul 1, 2024

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical information for custom compression garments or garments designated as “I/C.”

SourceLink

POLICY UPDATE CHANGES

Members who previously used ready-made garments and request a different type of replacement garment must be evaluated by a specialty therapist or chronic-edema treatment program.

The policy clarifies that custom garments require clinical records demonstrating medical necessity and that a letter alone is insufficient.

2 garmentsMaximum approved per affected extremity in each six-month period

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CurrentMedStar Family Choice, MarylandPolicy 1422

Custom Compression Garments for Diagnoses Excluding Lymphedema

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 1422 alerts

Get alerted when Policy 1422 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria for authorizing custom-fabricated compression garments and Maryland Medicaid Fee Schedule garments designated as “I/C” for members with non-lymphedema diagnoses.

Policy Summary

PayerMedStar Family Choice, Maryland

PolicyCustom Compression Garments for Diagnoses Excluding Lymphedema

Policy CodePolicy 1422

Change TypeMaterial update

Effective DateJul 1, 2024

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical information for custom compression garments or garments designated as “I/C.”

SourceLink

POLICY UPDATE CHANGES

Members who previously used ready-made garments and request a different type of replacement garment must be evaluated by a specialty therapist or chronic-edema treatment program.

The policy clarifies that custom garments require clinical records demonstrating medical necessity and that a letter alone is insufficient.

2 garmentsMaximum approved per affected extremity in each six-month period

Initial garment requirement elements

7 requirementsReplacement garment requirement elements

I/CMaryland Medicaid Fee Schedule designation subject to prior authorization

Medical Necessity and Coverage Requirements

Initial therapy

Covered when ALL initial garment requirements are met.

Initial garment requirements

Clinical condition and treatment: Severe edema is documented in the affected extremity, and the member is under the care of a specialty therapist or program that treats chronic edema.
Custom garment necessity: The specialist recommends custom compression garments, with a clear explanation of why prefabricated custom-fitted or standard items cannot be used. Practitioner and specialty therapy documentation must demonstrate medical necessity, and the clinical records must be dated before receipt of the garment request.
A letter stating why the garments are needed is not sufficient; clinical records must support medical necessity.
Prescription and measurement details: The amount of compression needed is documented by the specialist, and the required garment measurements and date taken are submitted.
Practitioner evaluation and member training: The ordering practitioner personally evaluated the member. Documentation shows that the member received training in proper donning and doffing techniques and demonstrated the ability to perform these tasks properly.
Wear-schedule education: The member was educated regarding the importance of continuing the wear schedule recommended by the specialist, and the submitted documentation demonstrates that this education was provided.
Quantity limit: The requested quantity does not exceed two garments per affected extremity every six months.Maximum of 2 garments per affected extremity every 6 months

Replacement therapy

Covered when ALL replacement garment requirements are met.

Replacement garment requirements

Clinical condition and garment condition: Severe edema is documented in the affected extremity, and the previous custom compression garment's integrity cannot be restored because the garment is worn out.
Measurements: The required garment measurements and date taken are submitted.
Skin and limb stability pathway
- Stable compared with initial fitting: The member's skin integrity and limb size are stable compared with the initial garment fitting, and a note from the member's practitioner attesting to this stability and an order from the practitioner are provided.
  The member does not need reevaluation by a specialty therapist under this pathway.

Custom compression garments and compression garments designated as “I/C” on the Maryland Medicaid Fee Schedule will not be approved unless the applicable initial or replacement coverage criteria are met.

Custom garments are not supported when the clinical documentation does not clearly establish why prefabricated custom-fitted or standard items cannot be used. The policy requires the most cost-efficient medically appropriate item; practitioner and specialty therapy records must demonstrate the medical necessity for a custom garment.

Coding and Quantity Parameters

Maryland Medicaid Fee Schedule designationmixed

I/C	Compression garments designated as ‘I/C’ on the Maryland Medicaid Fee Schedule

Garment quantity

Maximum quantityTwo garments per affected extremity

Approval periodEvery six months

Applies toInitial and replacement garment requests

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for custom compression garments and for compression garments designated as “I/C” on the Maryland Medicaid Fee Schedule. Submit the request with supporting clinical information in accordance with the MedStar Family Choice Prior Authorization Policy.

Documentation Required

Initial Medical Necessity Records

Before an initial garment request, submit dated clinical records documenting medical necessity and the member’s treatment for chronic edema. A specialty therapist or chronic-edema treatment program must be involved, and the specialist must recommend custom garments with documentation explaining why prefabricated custom-fitted or standard items cannot be used.

Document severe edema in the affected extremity.
Include records showing the member is under the care of a specialty therapist or program that treats chronic edema.
Submit the specialist’s recommendation for custom garments and the practitioner and specialty-therapy documentation supporting medical necessity and the most cost-efficient medically appropriate item.

Clinical Background

Compression garments apply graduated pressure to the affected area. This supports venous hemodynamics, reduces reflux, and helps decrease edema.

Key Terms

Compression garment

ItemAn item fabricated to apply varying amounts of pressure to an area

Venous supportRelieves stress on vein walls and aids muscle pumping function that restores venous hemodynamics and decreases reflux

Edema reductionIncreases tissue pressures that lead to decreased edema

Custom-fabricated garment

TypePrescription-grade garment

Manufacturing methodIndividually made for a specific patient

Also known asCustom-made garment

Policy Summary

PayerMedStar Family Choice, Maryland

PolicyCustom Compression Garments for Diagnoses Excluding Lymphedema

Policy CodePolicy 1422

Change TypeMaterial update

Effective DateJul 1, 2024

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical information for custom compression garments or garments designated as “I/C.”

SourceLink

On This Page

Not stable compared with initial fitting: The member's skin integrity or limb size is not stable compared with the initial garment fitting, and the member is reevaluated by a specialty therapist.

Prior garment type pathway: If the member previously used ready-made garments and the replacement request is for a different type of garment, the member is evaluated by a specialty therapist or program that treats chronic edema.

This conditional requirement is not triggered when the member did not previously use ready-made garments or the replacement is not for a different garment type.

Quantity limit: The requested quantity does not exceed two garments per affected extremity every six months.Maximum of 2 garments per extremity every 6 months

Clinical records supporting medical necessity must be dated before receipt of the garment request.

Include documentation that the member was trained in proper donning and doffing, demonstrated the ability to perform both tasks, and was educated on following the specialist’s recommended wear schedule.

A maximum of two garments per affected extremity every six months may be approved.

Documentation Required

Initial Garment Clinical Details

The initial request must include the clinical details needed to establish the garment ordered and the member’s ability to use it safely and effectively.

Document the amount of compression required by the specialist.
Submit required garment measurements and the date the measurements were taken.
The ordering practitioner must have personally evaluated the member.
Explain why custom garments are required when prefabricated custom-fitted or standard items cannot be used.

Documentation Required

Replacement Garment Records

Replacement requests require current documentation establishing the need for replacement and the condition of the prior garment. Submit the required records and measurements with the request.

Document severe edema in the affected extremity.
Document that the previous custom compression garment’s integrity cannot be restored because it is worn out.
Submit required garment measurements and the date the measurements were taken.
If the member previously used ready-made garments and the replacement is for a different garment type, document evaluation by a specialty therapist or chronic-edema treatment program.
A maximum of two garments per extremity every six months may be approved.

Documentation Required

Replacement Stability Documentation

When the member’s skin integrity and limb size are stable compared with the initial garment fitting, the practitioner must attest to that stability and provide an order. A specialty-therapist reevaluation is not required in this circumstance.

Include a practitioner note attesting that skin integrity and limb size are stable compared with the initial fitting.
Include the practitioner’s replacement order.
If skin integrity or limb size is not stable, the member must be re-evaluated by a specialty therapist.
If stability criteria are not met, do not rely solely on the practitioner note and order.

Denial Risk

Failure to Meet Medical Necessity Criteria

Custom compression garments and garments designated as “I/C” will not be approved unless all applicable initial or replacement criteria are met. Missing documentation or insufficient clinical support creates a denial risk.

Initial requests require all applicable medical-necessity, specialty-therapy, clinical-detail, training, education, and quantity criteria.
Replacement requests require all applicable edema, garment-integrity, measurement, stability or reevaluation, garment-type, and quantity criteria.
The requested item must be medically appropriate and cost efficient under the applicable requirements.

Denial Risk

Insufficient Clinical Documentation

A letter alone does not establish medical necessity for custom garments. Dated clinical records must support the request and must have been created before the garment request is received.

Submit the underlying practitioner and specialty-therapy clinical records, not only a narrative letter.
Records must clearly explain the need for custom garments and why prefabricated custom-fitted or standard items cannot be used.
Ensure the supporting records are dated prior to receipt of the request.

Denial Risk

Replacement Criteria Not Met

A replacement request may be denied when the prior garment can be restored or when required reassessment is not completed. Stability documentation is sufficient only when both skin integrity and limb size remain stable compared with the initial fitting.

Do not request replacement unless the previous custom garment’s integrity cannot be restored because it is worn out.
If skin integrity or limb size is not stable, obtain reevaluation by a specialty therapist.
If a ready-made garment is being replaced with a different garment type, obtain evaluation by a specialty therapist or chronic-edema treatment program.
Submit required measurements and the date they were taken.

Prefabricated custom-fitted garment

TypeReady-made garment

Manufacturing basisManufactured without a specific patient in mind

Fitting requirementsRequires a prescription and specific measurements to correctly fit a specific patient