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Minnesota Department of Human Services Provider Manual
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Pneumatic Compression Devices

Revised: 01-02-2013

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Pneumatic compression devices are used for treatment of chronic venous insufficiency of the lower extremities, lymphedema or peripheral artery disease.

    Eligible Providers

    The following providers may provide pneumatic compression devices and related supplies:

  • • Federally Qualified Health Center
  • • Home health agencies
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural Health Clinic
  • TPL and Medicare

    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.

    Eligible Recipients

    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.

    Covered Services

    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 use of appropriate compression bandage systems or compression garments
  • • Appropriate dressings for the wound
  • • Exercise
  • • Elevation of the limb
  • • Aggressive skin care
  • • 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:

  • • The use of appropriate compression bandage systems or compression garments
  • • Manual lymph massage
  • • Exercise
  • • Elevation of the limb
  • • Aggressive skin care
  • • Education in lymphedema self-management
  • • 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.

    Noncovered Services

  • • Appliances for use on the trunk, pelvis or chest (E0656, E0657) are not reimbursed separately from the compressor.
  • • Pneumatic compressors/appliances for indications other than peripheral artery disease, chronic venous insufficiency of the lower extremities or lymphedema are considered investigative.
  • Authorization

  • Authorization is always required for segmental pneumatic compression devices with calibrated gradient pressure. Authorization requests must include
  • • Documentation the recipient meets basic coverage criteria for pneumatic compression devices as described above (lack of efficacy of conservative treatment)
  • • Clinical notes detailing prior treatments
  • • Results of trial with non-segmental pneumatic compression devices (E0650)/segmental pneumatic compression devices without calibrated gradient pressure (E0651) or documentation of why a trial with these devices would not be safe or effective for the recipient
  • • Complete treatment plan including the prescribed pressure in each chamber and the frequency and duration of each treatment session
  • 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

  • • Documentation that the recipient has severe peripheral artery disease, established by vascular testing including ankle-brachial index, transcutaneous oximetry, Doppler ultrasound examination, etc.
  • • Documentation that all conservative treatment has been tried or considered and failed, and that the recipient will need surgical intervention if the device is not approved, or the recipient is not a candidate for surgery.
  • • For second and subsequent requests, documentation that the recipient has responded to treatment and continues to require treatment with the pneumatic compression device.
  • Authorization is always required for integrated appliances with 2 full legs and trunk. Authorization requests must include:

  • • Documentation the recipient meets basic coverage criteria for pneumatic compression devices as described above (lack of efficacy of conservative treatment)
  • • Clinical notes detailing prior treatments
  • • Description of the co-existing medical conditions that require the use of this appliance rather than other, less costly appliances.
  • • Complete treatment plan including the prescribed pressure in each chamber and the frequency and duration of each treatment session
  • Submit authorization request and required documentation to the Authorization Medical Review Agent.

    Billing

  • • Use MN–ITS 837P Professional
  • • Report the ordering provider in the Other Provider Types section of the MN–ITS Interactive claim
  • • Use the correct HCPCS code and modifier(s); NU or RR and KH, KI, KJ as appropriate
  • • Make sure the HCPCS code, modifiers and description match the authorization if appropriate
  • Refer to the Billing section on the main Equipment & Supplies page and the Detailed Written Orders section for additional information.

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