CurrentUnitedHealthcarePolicy CSNCT0563.08

Pneumatic Compression Devices (for North Carolina Only)

UnitedHealthcare Medical Policy applying only to North Carolina describing coverage reference to the North Carolina Medicaid Clinical Coverage Policy for pneumatic compression devices, lists applicable HCPCS procedure codes and FDA/device information. It defers medical necessity criteria to NC Medicaid policy 5A-1.

Policy Summary

PayerUnitedHealthcare

PolicyPneumatic Compression Devices (for North Carolina Only)

Policy CodePolicy CSNCT0563.08

Change TypeRevised HCPCS list; added codes

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen determining medical necessity for pneumatic compression devices in North Carolina, providers must follow the North Carolina Medicaid Clinical Coverage Policy 5A-1 (Physical Rehabilitation Equipment and Supplies).

POLICY UPDATE CHANGES

Updated list of applicable HCPCS codes to reflect quarterly edits; added E0658 and E0659.

20Listed HCPCS codes (count)

2Codes not on NC Medicaid Fee Schedule

Coverage Summary

This UnitedHealthcare Medical Policy applies only to the state of North Carolina and is identified as Policy Number CSNCT0563.08 with an effective date of January 1, 2026.

This policy defers medical necessity clinical coverage criteria to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy: 5A-1, Physical Rehabilitation Equipment and Supplies.

Medical-Necessity Criteria

Medical necessity determination

Coverage and medical necessity are determined by referring to the North Carolina Medicaid Clinical Coverage Policy 5A-1:

ALL of the following

This UnitedHealthcare policy applies only to the state of North Carolina.
For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Medical Equipment: 5A-1, Physical Rehabilitation Equipment and Supplies.

Applicable HCPCS / Procedure Codes

Applicable HCPCS / Procedure Codes (reference list)HCPCS

A4600	Sleeve for intermittent limb compression device, replacement only, each
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
E0658	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest
E0659	Segmental pneumatic appliance for use with pneumatic compressor, integrated, head, neck and 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

1–10 of 19

1/2

Codes not on State of North Carolina Medicaid Fee Schedule (may not be covered by NC Medicaid)HCPCSNot Covered

E0658	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest
E0659	Segmental pneumatic appliance for use with pneumatic compressor, integrated, head, neck and chest

Provider Actions & Billing Rules

Documentation Required

Follow NC Medicaid Clinical Criteria

When determining medical necessity for pneumatic compression devices in North Carolina, providers must follow the North Carolina Medicaid Clinical Coverage Policy 5A-1 (Physical Rehabilitation Equipment and Supplies).

North Carolina Medicaid Clinical Coverage Policy 5A-1

Billing Rule

HCPCS code applicability and state fee schedule

Codes marked with an asterisk are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program; providers should verify coverage and reimbursement against state/contractual requirements.

Affected HCPCS codes: E0658
Affected HCPCS codes: E0659
Verify coverage and reimbursement against state and contractual requirements

Background & Device Information

The policy provides a reference list of applicable HCPCS procedure codes for pneumatic compression devices (listed for reference and not implying coverage or reimbursement). Codes included in the list (examples shown in the policy) include A4600, E0650, E0651, E0652, E0655, E0658, E0659, E0660, E0665, E0666, E0667, and others.

The policy notes that codes marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program (the policy specifically added notation that HCPCS codes E0658 and E0659 are not on the State of North Carolina Medicaid Fee Schedule).

FDA clearance information is provided for relevant devices: the policy notes that the Flexitouch Plus System (Tactile Systems Technology, Inc) received FDA clearance on December 20, 2020 for treatment of head and neck lymphedema, and it states that devices and systems to perform pneumatic compression are regulated as FDA Class II devices.

Evidence type	Details
FDA clearance	Flexitouch Plus System (Tactile Systems Technology, Inc) cleared December 20, 2020 for treatment of head and neck lymphedema

Revision History

01/01/2026revisedLatest

Updated list of applicable HCPCS codes to reflect quarterly edits; added E0658 and E0659. Added notation that HCPCS codes E0658 and E0659 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid. Archived previous policy version CSNCT0563.07.