Does E0671 require prior authorization?

No, E0671 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`E0671`, Segmental gradient pressure pneumatic appliance, full leg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

For repeat trigeminal neuralgia cryoanalgesia: documentation supporting prior benefit and that repeat procedure is at least 6 months after prior cryoanalgesia.
For passive cold compression therapy as DME: clinical documentation supporting the need to control swelling, edema, hematoma, hemarthrosis and pain (i.e., reason for DME), and appropriate physician order for DME.
When CPT/HCPCS coding is used, documentation must support that the procedure/code corresponds to an indication covered by this CPB (i.e., link diagnosis, procedure note, operative report or DME order to the covered indication).

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.
ICD-10 G50.0: Trigeminal neuralgia (covered if selection criteria are met)
Use of CPT codes 64600 (destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch) and 64620 (destruction by neurolytic agent, intercostal nerve) when furnished for the indications listed in this CPB.
Selected ICD-10 diagnoses may be covered when selection criteria are met (examples listed in the CPB include G50.0 Trigeminal neuralgia; various joint effusion/hemarthrosis/pain codes; edema and swelling codes; pain codes), noting coverage is diagnosis- and criteria-dependent.
Cryoanalgesia for the temporary relief of pain due to chronic refractory trigeminal neuralgia (subject to Appendix selection criteria).
Pre-operative, intra-operative, and post-operative cryoanalgesia for post-operative pain management related to the Nuss procedure (pectus excavatum repair).

17 Active Policies

ANTHEM-CG-DME-46, Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

ANTHEM-CG-DME-06, Compression Devices for Lymphedema

UHC-POL-pneumatic-compression-devices, Pneumatic Compression Devices

AETNA-CPB-0297, Cryoanalgesia and Therapeutic Cold

AETNA-CPB-0069, Lymphedema

CIGNA-0354, Compression Devices

BCBSIL-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers

BCBSIL-MED202.073, Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

BCBSMT-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers

BCBSMT-MED202.073, Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

BCBSNM-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers

BCBSNM-MED202.073, Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

BCBSOK-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers

BCBSOK-MED202.073, Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

REGENCE-DME90, Postsurgical Home Use of Limb Compression Devices

UMR-POL-UMR-pneumatic-compression-devices, Pneumatic Compression Devices

SUREST-POL-SUREST-pneumatic-compression-devices, Pneumatic Compression Devices

`E0671`, Segmental gradient pressure pneumatic appliance, full leg

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

E0671, Segmental gradient pressure pneumatic appliance, full leg

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`E0671`, Segmental gradient pressure pneumatic appliance, full leg