ModifiedModa HealthPolicy N/A

Custom Compression Garments

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This policy governs Moda Health coverage and prior authorization requirements for custom-ordered, fitted, ready-made, and custom compression garments used to treat specified edema, venous, lymphatic, thrombotic, and related conditions. It applies to providers requesting coverage for members who meet the clinical, prescription, measurement, pressure, and conservative-management requirements.

Policy Summary

PayerModa Health

PolicyCustom Compression Garments

Policy CodePolicy N/A

Change TypeModified — codes added

Effective DateNov 1, 2026

Last ReviewOct 28, 2026

Next Review DateN/A

Key ActionSubmit prescribing-provider clinical or chart notes and the treating physician's prescription and order with required fitting measurements.

SourceLink

POLICY UPDATE CHANGES

The October 2026 annual review added codes to the policy.

18 mmHgMinimum required gradient pressure

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ModifiedModa HealthPolicy N/A

Custom Compression Garments

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Know when Moda Health releases new policies or updates existing guidance.

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Policy Summary

PayerModa Health

PolicyCustom Compression Garments

Policy CodePolicy N/A

Change TypeModified — codes added

Effective DateNov 1, 2026

Last ReviewOct 28, 2026

Next Review DateN/A

Key ActionSubmit prescribing-provider clinical or chart notes and the treating physician's prescription and order with required fitting measurements.

SourceLink

POLICY UPDATE CHANGES

The October 2026 annual review added codes to the policy.

18 mmHgMinimum required gradient pressure

Maximum stocking pairs per six months

13Qualifying indication categories

40+ mmHgHighest listed compression pressure

6 monthsSupply interval

Coverage Criteria

Initial coverage criteria

Covered when all of the following requirements are met.

Required elements

Prescription and fitting measurements: A physician or other qualified health care professional has provided a prescription and the required measurements for fitting.
Gradient pressure: The garment has a gradient pressure aid with a degree of pressure of at least 18 mmHg.at least 18 mmHg
Failed conservative management: Conservative management, such as exercise or weight management, has failed to show improvement in symptoms.
Qualifying indication — one or more
- Chronic lymphedema, including lymphedema as a complication of mastectomy.
- Pregnancy or postpartum DVT prophylaxis: Deep vein thrombosis prophylaxis during pregnancy and postpartum.
- Severe edema in pregnancy.
- Pregnancy-related varicose veins: Moderate to severe varicose veins during pregnancy.moderate to severe
- Post-mastectomy edema.
- Neurologic-condition edema: Edema with paraplegia, quadriplegia, or similar conditions.

Quantity and replacement criteria

Quantity and replacement coverage are subject to the following conditions.

Supply and replacement requirements

Standard quantity: A maximum of 2 pairs of pressure-gradient support stockings every six months is considered medically necessary.maximum of 2 pairs every six months
Additional support garments are covered when the member's primary physician determines they are needed because of significant weight gain or loss and/or a change in the member's condition.
This requirement applies to garments beyond the standard maximum of 2 pairs every six months.
Replacement garments: Replacements are medically necessary when the member's condition changes and the member's physician determines that replacement is needed and provides clinical documentation indicating the condition changes necessitating the replacement.

Compression garments used to decrease scarring for cosmetic purposes are not covered.

Compression garments used for comfort or recreational purposes are not covered.

Because of a lack of peer-reviewed literature evaluating their clinical use, compression garments for lymphedema of the chest, trunk, neck, or labia are considered experimental and investigational. Examples include vests, Tribute vests, and torso garments such as Solaris.

Compression garments for treatment of severe peripheral arterial disease or septic phlebitis are considered experimental and investigational because compression is contraindicated in these conditions.

Coding and Quantity Parameters

Covered HCPCS CodesHCPCSCovered

A6549	Gradient compression stocking/sleeve, not otherwise specified
A4465	Nonelastic binder for extremity
A6515	Gradient compression wrap with adjustable straps, full leg, custom, each
A6516	Gradient compression wrap with adjustable straps, hand, standard, each
A6521	Gradient compression garment, glove, padded, for nighttime use, custom, each
A6523	Gradient compression garment, arm, padded, for nighttime use, custom, each
A6525	Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each
A6527	Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each
A6529	Gradient compression garment, bra, for nighttime use, custom, each
A6553	Gradient compression stocking, below knee, 30-40 mmHg, custom, each

1–10 of 32

1/4

Not Covered HCPCS CodesHCPCSNot Covered

No codes listed

Minimum Gradient Pressure

Minimum required pressureAt least 18 mmHg of gradient pressure

Applies toCustom-ordered or fitted compression garments, including gradient pressure aid garments or sleeves

Coverage conditionThe garment must meet the pressure requirement along with the policy’s other medical-necessity criteria

Standard Stocking Quantity

Standard quantity limitA maximum of 2 pairs of pressure-gradient support stockings every six months

Additional garmentsAdditional support garments may be covered when the member’s primary physician determines they are needed because of significant weight gain or loss and/or a change in the member’s condition

Provider Actions and Review Risks

Prior Authorization

Prior Authorization Documentation Required

Submit clinical or chart notes from the prescribing provider and the treating physician’s prescription/order with the prior authorization request for custom compression garments.

Clinical or chart notes must detail the medical need for the custom compression stockings.
Include the treating physician’s prescription and physician order.

Documentation Required

Prescribing Provider Clinical Notes

The prescribing provider must document the clinical need for the custom compression stockings in the submitted chart or clinical notes.

Documentation should support the diagnosis, symptoms, failed conservative management, and requested garment.

Unsupported block type: documentation

Policy Background

Compression garments provide external pressure that promotes movement of fluid from the interstitial space into the vascular system and improves venous and lymphatic return. Graduated stockings apply the greatest pressure at the ankle, with pressure decreasing proximally; this can reduce venous reflux, increase blood-flow velocity, augment the skeletal muscle pump, and improve lymphatic drainage.

Definitions

Graduated Compression Stocking

DefinitionA compression garment or stocking that exerts the greatest degree of compression at the ankle and gradually decreases compression up the garment

Pressure patternThe pressure gradient promotes upward blood flow toward the heart instead of downward reflux toward the foot or superficial veins

Clinical effectAdequate graduated compression can increase blood-flow velocity and volume, augment the skeletal muscle pump, facilitate venous return, and improve lymphatic drainage

Compression Therapy

DefinitionExternal compression used to enhance the return of fluid from the interstitial space to the vascular system

Primary purposeSupport venous and lymphatic drainage

Medical Necessity

Compression garment medical necessity

Custom compression garments are medically necessary when all core requirements are met and at least one qualifying indication is present.

Core medical-necessity requirements

Prescription and fitting measurements: A physician or other qualified health care professional has provided a prescription and the required measurements for fitting.
Minimum gradient pressure: The garment has a gradient pressure aid with a degree of pressure of at least 18 mmHg.at least 18 mmHg
Conservative management, such as exercise or weight management, has failed to show improvement in symptoms.
Qualifying indication — one or more

Replacement and Supply Limits

Replacement and Quantity Limits

Replacement intervalNo fixed replacement interval is stated

Standard quantity limitA maximum of 2 pairs of pressure-gradient support stockings every six months

Replacement requirementReplacement is medically necessary when the member’s condition changes and the member’s physician determines replacement is needed and provides clinical documentation supporting the change

Required Documentation

Prior Authorization

Submit the complete documentation package

Submit the treating physician’s prescription and physician order together with clinical or chart notes from the prescribing provider documenting the need for the custom compression stockings. The prescription must include the measurements required for fitting.

Documentation Required

Document medical necessity for replacement

For replacement garments, the member’s physician must determine that the condition changed and provide clinical documentation indicating why replacement is necessary.

Not Covered and Investigational Uses

The following uses are not covered: compression garments for cosmetic scar reduction or for comfort or recreational purposes. Garments for lymphedema of the chest, trunk, neck, or labia are considered experimental and investigational because of a lack of peer-reviewed literature. Garments for treatment of severe peripheral arterial disease or septic phlebitis are also considered experimental and investigational because they are contraindicated in these conditions.

Policy Summary

PayerModa Health

PolicyCustom Compression Garments

Policy CodePolicy N/A

Change TypeModified — codes added

Effective DateNov 1, 2026

Last ReviewOct 28, 2026

Next Review DateN/A

Key ActionSubmit prescribing-provider clinical or chart notes and the treating physician's prescription and order with required fitting measurements.

SourceLink

On This Page

Post-traumatic or postoperative edema: Edema following surgery, fracture, burns, or any other trauma.

Immobilization thrombosis prevention: Prevention of thrombosis in immobilized persons, including immobilization due to surgery, trauma, or general debilitation.

Postural hypertension with documented changes in systolic or diastolic pressures.documented changes in systolic or diastolic pressures

Post-sclerotherapy: Post sclerotherapy.

Post-thrombotic syndrome, also called post-phlebitic syndrome.

Orthostatic hypotension.

Chronic venous insufficiency complications: Treatment of complications of chronic venous insufficiency, including lipodermatosclerosis, stasis dermatitis or venous eczema, varicose veins except spider veins, venous edema, or venous ulcers or stasis ulcers.

Spider veins are excluded from the listed varicose-vein indication.

Covered garment typesReady-made or custom-made compression garments may be covered

Denial Risk

Core Medical-Necessity Criteria

Coverage requires all core medical-necessity elements: an appropriate prescription and fitting measurements, a gradient pressure garment of at least 18 mmHg, failed conservative management, and at least one covered clinical indication.

Covered indications include chronic lymphedema; DVT prophylaxis during pregnancy and postpartum; severe edema or moderate-to-severe varicose veins during pregnancy; post-mastectomy edema; edema associated with paraplegia or quadriplegia; edema after surgery, fracture, burns, or other trauma; thrombosis prevention during immobilization; postural hypertension with documented systolic/diastolic changes; post-sclerotherapy; post-thrombotic syndrome; and orthostatic hypotension.
Also covered are complications of chronic venous insufficiency, including lipodermatosclerosis, stasis dermatitis, varicose veins other than spider veins, venous edema, and venous ulcers.

Billing Rule

Additional Garments Require Documented Need

A maximum of two pairs of pressure-gradient support stockings every six months is medically necessary. Additional garments require the member’s primary physician to document the need because of significant weight gain or loss and/or a change in the member’s condition.

Document the physician-determined reason for any request exceeding two pairs in six months.

Denial Risk

Excluded or Investigational Uses

Compression garments are not covered for cosmetic scar reduction or comfort/recreational use. Garments for chest, trunk, neck, or labia lymphedema are considered experimental and investigational, as are garments for severe peripheral arterial disease or septic phlebitis because compression is contraindicated.

Examples of potentially excluded anatomical garments include vests, Tribute vests, and torso garments such as Solaris.
Do not submit cosmetic or recreational use as a covered indication.

Conditions addressedFrequently used for venous and lymphatic insufficiency, including varicosities, lymphedema, venous eczema and ulceration, deep vein thrombosis, and post-thrombotic syndrome

Chronic lymphedema, including lymphedema as a complication of mastectomy.
Pregnancy or postpartum DVT prophylaxis: Deep vein thrombosis prophylaxis during pregnancy and postpartum.
Severe edema in pregnancy.
Pregnancy-related varicose veins: Moderate to severe varicose veins during pregnancy.
Post-mastectomy edema.
Neurologic-condition edema: Edema with paraplegia, quadriplegia, or similar conditions.
Post-traumatic or postoperative edema: Edema following surgery, fracture, burns, or any other trauma.
Immobilization thrombosis prevention: Prevention of thrombosis in immobilized persons, including immobilization due to surgery, trauma, or general debilitation.
Postural hypertension with documented changes in systolic or diastolic pressures.
Post-sclerotherapy: Post sclerotherapy.
Post-thrombotic syndrome, also called post-phlebitic syndrome.
Orthostatic hypotension.
Chronic venous insufficiency complications: Treatment of complications of chronic venous insufficiency, including lipodermatosclerosis, stasis dermatitis or venous eczema, varicose veins except spider veins, venous edema, or venous ulcers or stasis ulcers.
Spider veins are excluded from the listed varicose-vein indication.