Lymphedema Pump and Appliances (E0650-E0673)
Pneumatic compression devices are covered for the treatment of lymphedema (457.0, 457.1, 757.0) or for the treatment of chronic venous insufficiency with venous stasis ulcers (459.81).

NOTE:

Pneumatic compression devices used for the treatment of arterial insufficiency (E0675) are considered experimental/investigational, and are not eligible for reimbursement. Despite the fact that these devices have received FDA approval, there is a lack of long-term studies demonstrating the efficacy of these devices. A participating, preferred, or network provider can bill the member for the denied device.

Date Last Reviewed:  01/2006

Lymphedema
When prescribed by a physician, the rental or purchase of an intermittent compression unit (segmental, non-segmental) for home use is warranted when lymphedema of the arm or leg exists.

Chronic Venous Insufficiency (CVI)
When prescribed by a physician, 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) that 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.

Pneumatic intermittent compression units/lymphedema pumps and appliances may be covered as durable medical equipment (DME) only as a prescription item with appropriate physician oversight (i.e., physician evaluation of the patient's condition to determine medical necessity of the device, suitable instruction in the operation of the machine as to the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment).

When pneumatic compression devices are provided for conditions other than those listed, they will be denied as not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service.

Intermittent Compression Therapy
Intermittent compression therapy can also be provided in the provider's office as a physical medicine modality (code 97016). This treatment is warranted for the following conditions:

1. Edema of the extremities (757.0, 782.3)
2. Hematoma of the leg (924.00, 924.10, 924.4, 924.5)
3. Lymphedema of the arm (457.0 457.1)
4. Lymphedema of the leg (457.1, 757.0)
5. Venous insufficiency or venous stasis disorder (459.81)

Conditions other than those listed above or those which indicate that an infection is present should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Documentation to support the application of a compression device should include the type, amount and location of the edema as well as the circumferential measurements of the treated extremity, before and after treatment.

Syncardon Therapy
Syncardon therapy (97139) has not been proven to be medically efficacious in the treatment of lymphedema of the extremities. Therefore, Syncardon therapy should be denied as not medically necessary. The rental or purchase of a Syncardon unit (E1399) for home use should also be denied in the same manner. A participating, preferred, or network provider cannot bill the member for the denied service.

Coverage for outpatient physical medicine and/or durable medical equipment (DME) is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

Lymphedema Pump and Appliances
A pneumatic intermittent compression unit/lymphedema pump, (e.g., Jobst pneumatic compressor) consists of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.

Lymphedema
Lymphedema occurs when the lymph flow from an extremity is compromised because of obstructed or inadequate lymphatic vessels. It involves 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.

Chronic Venous Insufficiency (CVI)
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.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PRN References

02/2004, Blue Shield considers pneumatic compression devices to treat arterial insufficiency investigational

06/2006, Application of a vasopneumatic device eligible for specific indications

MCIM 60-9, 60-16

Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease, Wound, Ostomy, and Continence Nurses Society - Professional Assoc., June 2002

Rapid Foot and Calf Compression Increases Walking Distance in Patients with Intermittent Claudication; Results of a Randomized Study, J Vasc Surg, May 1, 2005; 41(5): 794-801

Hemodynamic Effects of Intermittent Pneumatic Compression in Patients with Critical Limb Ischemia, J Vasc Surg, October 1, 2005; 42(4): 710-716