Pneumatic compression devices are used for treatment of chronic venous insufficiency of the lower extremities, lymphedema or peripheral artery disease.
The following providers may provide pneumatic compression devices and related supplies:
Providers must meet any provider criteria, including accreditation, for third party insurance or Medicare in order to assist recipients for whom MHCP is not the primary payer.
Pneumatic compression devices are covered for eligible MHCP recipients with chronic venous insufficiency of the lower extremities or lymphedema that has not responded to other treatment options.
Codes: E0650 – E0652 and E0675 (Pneumatic compressors), and E0653 - E0673 (appliances for use with pneumatic compressor)
Only compressors approved by the Food and Drug Administration (FDA) are covered. Only appliances approved by the FDA for use on extremities are covered.
Non-segmental pneumatic compression devices (E0650), and segmental pneumatic compression devices without calibrated gradient pressure (E0651), are covered without authorization for treatment of chronic venous insufficiency of the lower extremities when the recipient has had one or more lower extremity venous stasis ulcers and meets the following criteria:
• The recipient has undergone at least six months of conservative therapy. Conservative therapy includes:
• The venous stasis ulcer has failed to heal after a six month trial.
Non segmental pneumatic compression devices (E0650) and segmental pneumatic compression devices without calibrated gradient pressure (E0651) are covered without authorization for treatment of lymphedema when the recipient meets the following criteria:
• The recipient has undergone at least four weeks of conservative therapy. Conservative therapy includes:
• No significant improvement has occurred or significant symptoms remain following a four week trial.
One segmental or non-segmental appliance for each affected extremity is covered per year for use with a medically necessary pneumatic compressor. A new order is required for replacement of an appliance.
Prior to dispensing the pneumatic compressor and appliances, the medical supplier must obtain documentation from the physician detailing the conservative treatment that was tried and failed.
Segmental pneumatic compression devices with calibrated gradient pressure (E0652) are covered with authorization when the recipient’s medical condition cannot be safely and effectively treated with non-segmental devices or with segmental devices without calibrated gradient pressure.
Integrated appliances with 2 full legs and trunk (E0670) are covered with authorization for recipients that cannot use other appliances due to co-existing medical conditions, including obesity.
High pressure, rapid cycling pneumatic compression devices (E0675) are covered with authorization for treatment of peripheral artery disease for patients who might otherwise require surgical treatment of the arterial insufficiency.
Authorization is always required for high pressure, rapid inflation/deflation cycle pneumatic compression devices. Authorization will be made for up to 3 months at a time, for a maximum of 14 months (the capped rental period). Authorization requests must include
Authorization is always required for integrated appliances with 2 full legs and trunk. Authorization requests must include:
Submit authorization request and required documentation to the Authorization Medical Review Agent.
Refer to the Billing section on the main Equipment & Supplies page and the Detailed Written Orders section for additional information.Report/Rate this page