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HCPCS/CPT K1025, Non-pneumatic sequential compression garment, full arm | No Prior Auth

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`K1025`, Non-pneumatic sequential compression garment, full arm

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

Single or multi-chamber or segmentnon-programmablecompression devices are consideredmedically necessarywhen the criteria below have been met:
Treatment of upper or lower limb lymphedema;and
The individualâs lymphedema is not improving;and
The individual has been compliant with conservative therapy*.
*Conservative therapy may include any combination of the following: elevation of the affected limb, exercise, massage, use of an appropriate compression bandage system or compression garment.
Single or multi-chamber or segmentprogrammable(for example, calibrated gradient pressure) compression devices are consideredmedically necessarywhen the criteria below have been met:

1 Active Policy

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

Related Codes

C50.A2(1 policies)C79.81(1 policies)D05.00(1 policies)D05.92(1 policies)D48.60(1 policies)D48.62(1 policies)D49.3(1 policies)C50.011(1 policies)

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