HCPCS/CPT E0655, Non-segmental pneumatic appliance for use with pneumatic compressor, half arm | Prior Auth Required

HCPCS/CPT E0655, Non-segmental pneumatic appliance for use with pneumatic compressor, half arm | Prior Auth Required

Key Coverage Criteria

Pneumatic compression devices are medically necessary for the treatment of lymphedema or chronic venous insufficiency (CVI) with edema and non-healing lower extremity ulcers.
A standard pneumatic compression device (HCPCS code E0650, E0651) and associated appliances (HCPCS code E0655, E0660, E0665-E0669, E0671-E0673) used in the home setting are considered medically necessary for EITHER of the following:
- for the treatment of intractable lymphedema when there is failure of a four-week trial of conservative medical management including ALL of the following: > home exercise program > limb elevation > compression bandage or compression garment use
- for the treatment of chronic venous insufficiency (CVI) with venous stasis ulcer(s) of lower extremities when BOTH of the following criteria are met: > The individual has received medically-supervised treatment of the ulcer(s) for at least 24 weeks using standard wound care treatment, including compression, wound dressings, exercise, and elevation of the limb. > Failure of the ulcer(s) to decrease in size or demonstrate improvement despite conventional therapy.
A pneumatic compression device with calibrated gradient pressure (HCPCS code E0652) and associated appliances (HCPCS code E0656-E0657, E0667-E0670) used in the home setting are considered medically necessary when BOTH of the following criteria are met: - individual meets above criteria for a standard pneumatic compression device - EITHER of the following: > documented failure of relief with standard pneumatic compression device > individual requires specified pressure to a localized area
Continuation of use of a pneumatic compression device is considered medically necessary when BOTH of the following criteria are met: - there is adherence with the use of equipment as ordered by the healthcare professional - clinical documentation from the health care professional confirms clinical improvement (e.g., improvement in venous stasis ulcers, decrease in edema or lymphedema)