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CPT codes, descriptions and other data only are copyright 2006
American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental
Terminology, (CDT) (including procedure codes, nomenclature, descriptors
and other data contained therein) is copyright by the American Dental
Association. © 2002, 2004 American Dental Association. All rights reserved.
Applicable FARS/DFARS apply.
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For any item to be covered by Medicare, it must 1) be eligible
for a defined Medicare benefit category, 2) be reasonable and necessary for
the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
medical policy, the criteria for "reasonable and necessary" are
defined by the following indications and limitations of coverage and/or
medical necessity.
For an item to be covered by Medicare, a written signed and dated order
must be received by the supplier before a claim is submitted. If the
supplier bills for an item addressed in this policy without first receiving
the completed order, the item will be denied as not medically necessary.
Pneumatic compression devices are only covered for the treatment of
lymphedema or for the treatment of chronic venous insufficiency with venous
stasis ulcers. If the coverage criteria below are not met the devices will
be denied as not medically necessary.
LYMPHEDEMA:
Lymphedema is the swelling of subcutaneous tissues due to the accumulation
of excessive lymph fluid. The accumulation of lymph fluid results from
impairment to the normal clearing function of the lymphatic system and/or
from an excessive production of lymph. Lymphedema is divided into two broad
classes according to etiology. Primary lymphedema is a relatively uncommon,
chronic condition which may be due to such causes as Milroy's Disease or
congenital anomalies. Secondary lymphedema, which is much more common,
results from the destruction of or damage to formerly functioning lymphatic
channels, such as radical surgical procedures with removal of regional
groups of lymph nodes (for example, after radical mastectomy), post-radiation
fibrosis, and spread of malignant tumors to regional lymph nodes with
lymphatic obstruction, among other causes.
Pneumatic compression devices are covered in the home setting for the
treatment of lymphedema if the patient has undergone a four-week trial of
conservative therapy and the treating physician determines that there has
been no significant improvement or if significant symptoms remain after the
trial. The trial of conservative therapy must include use of an appropriate
compression bandage system or compression garment, exercise, and elevation
of the limb. The garment may be prefabricated or custom-fabricated but must
provide adequate graduated compression.
CHRONIC VENOUS INSUFFICIENCY WITH VENOUS STASIS ULCERS:
Chronic venous insufficiency (CVI) of the lower extremities is a condition
caused by abnormalities of the venous wall and valves, leading to
obstruction or reflux of blood flow in the veins. Signs of CVI include
hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.
Pneumatic compression devices are covered in the home setting for the
treatment of CVI of the lower extremities only if the patient has one or
more venous stasis ulcer(s) which have failed to heal after a six month
trial of conservative therapy directed by the treating physician. The trial
of conservative therapy must include a compression bandage system or
compression garment, appropriate dressings for the wound, exercise, and
elevation of the limb.
GENERAL COVERAGE CRITERIA:
For either lymphedema or CVI with venous stasis ulcers, pneumatic
compression devices are covered only when prescribed by a physician and
when they are used with appropriate physician oversight, i.e., physician
evaluation of the patient's condition to determine medical necessity of the
device, assuring suitable instruction in the operation of the machine, a
treatment plan defining the pressure to be used and the frequency and
duration of use, and ongoing monitoring of use and response to treatment.
The determination by the physician of the medical necessity of a pneumatic
compression device must include (1) the patient's diagnosis and prognosis;
(2) symptoms and objective findings, including measurements which establish
the severity of the condition; (3) the reason the device is required,
including the treatments which have been tried and failed; and (4) the
clinical response to an initial treatment with the device. The clinical
response includes the change in pre-treatment measurements, ability to
tolerate the treatment session and parameters, and ability of the patient
(or caregiver) to apply the device for continued use in the home.
When a pneumatic compression device is covered, a non-segmented device
(E0650) or segmented device without manual control of the pressure in each
chamber (E0651) is generally sufficient to meet the clinical needs of the
patient. A non-segmented compressor (E0650) with a segmented
appliance/sleeve (E0671- E0673) is considered functionally equivalent to an
E0651 compressor with a segmented appliance/sleeve (E0667-E0669). When a
segmented device with manual control of the pressure in each chamber
(E0652) is ordered and provided, payment will be based on the allowance for
the least costly medically appropriate alternative, E0651, unless there is
clear documentation of medical necessity in the individual case. Full
payment for code E0652 will be made only when there is documentation that
the individual has unique characteristics that prevent satisfactory
pneumatic compression treatment using a non-segmented device (E0650) with a
segmented appliance/sleeve (E0671- E0673) or a segmented device without
manual control of the pressure in each chamber (E0651).
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