Does E0675 require prior authorization?

Yes, E0675 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

Backwork Sign up free

`E0675`, Pneumatic compression device, high pressure, rapid inflation/deflation cycle,

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

Applies only to pre-made or custom-made pressure gradient support stockings that have a pressure of 18 mm Hg or more, that require a physician's prescription, and that require measurements for fitting
Physician's prescription is required for graded compression stockings (policy repeatedly notes requirement of a physician's prescription)
Measurements for fitting are required for pre-made or custom-made pressure gradient support stockings

Replacements are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member's physical condition (documentation should support unrepairable damage or change in physical condition)

Selection criteria / medical condition documentation: documentation must support one of the listed covered indications/diagnoses (e.g., venous ulcers, lymphedema, post-thrombotic syndrome, orthostatic hypotension, immobilization, severe pregnancy edema, paraplegia/quadriplegia-associated edema, edema after surgery/trauma/burns, post sclerotherapy)

Benefit-plan documentation: determine member's benefit plan coverage for graded compression stockings or non-elastic binders (Aetna's standard benefit plans exclude them as outpatient consumable/disposable supply)

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.
Persons with lymphedema (see CPB 0069 - Lymphedema)
Treatment of any of the following complications of chronic venous insufficiency: Varicose veins (except spider veins)
Treatment of any of the following complications of chronic venous insufficiency: Venous edema
Treatment of any of the following complications of chronic venous insufficiency: Venous ulcers (stasis ulcers)
Treatment of any of the following complications of chronic venous insufficiency: Stasis dermatitis (venous eczema)

14 Active Policies

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

ANTHEM-DME.00037, Cooling Devices and Combined Cooling/Heating Devices

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

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

AETNA-CPB-0482, Compression Garments for the Legs

AETNA-CPB-0500, Intermittent Pneumatic Compression Devices

AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines

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

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

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

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

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

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

CIGNA-0354, Compression Devices

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about E0675 Sign up free

E0675, Pneumatic compression device, high pressure, rapid inflation/deflation cycle,