Pneumatic and Nonpneumatic Compression Devices

Revised: September 30, 2025

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing

Overview

Pneumatic and nonpneumatic compression devices are used for treatment of chronic venous insufficiency of the lower extremities, lymphedema, peripheral artery disease, or deep venous thrombosis. They are used concurrently with gradient compression garments, stockings, and banding supplies. Compressors may be pneumatic, which use air to remove excess fluid, or nonpneumatic, which use other mechanisms. Compressors and appliances may be nonsegmented (a single chamber) or segmented (multiple chambers) with or without calibrated gradient pressure. Treatment utilizes limb elevation, gradient pressure garments, stockings, or sleeves, and compression bandaging supplies.

Eligible Providers

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

· Federally qualified health centers

· Home health agencies

· Indian Health Services

· Medical suppliers

· Pharmacies

· Rural health clinics

TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or Medicare to assist members for whom MHCP is not the primary payer.

Eligible Members

Pneumatic and nonpneumatic compression devices are covered for eligible Medical Assistance and MinnesotaCare members with chronic venous insufficiency of the lower extremities, peripheral artery disease, deep venous thrombosis, or lymphedema and are not responding to other treatment options.

Covered Services

Codes: A6501-A6513, A6520-A6541, A6544-A6545, A6549-A6550, A6552-A6589, A6593-A6610, E0650-E0652, E0655-E0660, E0665-E0673, E0675-E0683
MHCP covers compressors, appliances, and gradient compression garments, stockings, sleeves, and bandaging supplies for eligible members. Only compressors approved by the U.S. Food and Drug Administration are covered. MHCP covers one pneumatic or nonpneumatic compressor and appliances per five years when less intensive treatments have not been effective.

MHCP covers the following items for lymphedema compression treatments:

· Standard daytime gradient compression garments

· Custom daytime gradient compression garments

· Nighttime gradient compression garments

· Gradient compression wraps

· Compression bandaging supplies

MHCP covers three units of daytime gradient compression garments per each impacted extremity every six months. Two nighttime garments per each impacted extremity are covered every two years.

Nonsegmental 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 member has had one or more lower extremity venous stasis ulcers and meets the following criteria:

· The member 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.

Nonsegmental pneumatic compression devices (E0650) and segmental pneumatic compression devices without calibrated gradient pressure (E0651) are covered with authorization for treatment of lymphedema when the member meets the following criteria:

· The member has undergone at least four weeks 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

· No significant improvement has occurred, or significant symptoms remain after a four-week trial.

Before dispensing the compressor and appliances, the medical supplier must obtain documentation from the ordering physician detailing the conservative treatment that was tried and failed.

One appliance for each affected extremity is covered per year for use with a medically necessary compressor. A new order is required for replacement of an appliance.

Segmental pneumatic compression devices with calibrated gradient pressure (E0652), nonpneumatic compression controllers with sequential calibrated gradient pressure (E0680), and nonpneumatic compression controllers without calibrated gradient pressure (E0681) are covered with authorization when the recipient’s medical condition cannot be safely and effectively treated with pneumatic nonsegmental devices or with segmental devices without calibrated gradient pressure.

Integrated appliances with two full legs and trunk (E0670), two full arms and chest (E0658), and the head, neck, and chest (E0659) are covered with authorization for members that have multiple lesions or cannot use other appliances due to coexisting medical conditions, including obesity. Integrated appliances include payment for all impacted areas of the body. There is no separate payment for multiple appliances in conjunction with integrated appliances or when the member’s medical needs may be satisfied with an integrated appliance.

High-pressure, rapid-cycling pneumatic compression devices (E0675) are covered with authorization for treatment of peripheral artery disease for members who might otherwise require surgical treatment of the arterial insufficiency.

Intermittent limb compression devices (E0676) and nonpneumatic, nonsequential, peristaltic wave compression pumps (E0683) are covered with authorization for prevention of deep venous thrombosis.

Refer to the Medical Supply Coverage Guide (PDF) for authorization requirements and quantity limits.

Noncovered Services

MHCP does not cover compressors and appliances for indications other than chronic venous insufficiency of the lower extremities, peripheral artery disease, deep venous thrombosis, or lymphedema. These devices are considered investigative and substantive research is lacking.

Authorization

Authorization is required for the following:

· Segmental pneumatic compression devices with calibrated gradient pressure (E0652)

· Integrated appliances with two full legs and trunk (E0670)

· Integrated appliances with two full arms and chest (E0658)

· Integrated appliances with head, neck, and chest (E0659)

· High-pressure, rapid-cycling pneumatic compression devices (E0675)

· Intermittent limb compression devices (E0676)

· Nonpneumatic compression controller with sequential calibrated gradient pressure (E0680)

· Nonpneumatic compression controller without calibrated gradient pressure (E0681)

· Nonpneumatic appliances (E0677 to E0679, E0682)

· Nonpneumatic, nonsequential, peristaltic wave compression pump (E0683)

Documentation for authorization requests must include:

· Member’s diagnosis; and

· Order; and

· Clinical history, including prior treatments and failure of conservative treatment; and

· Location and size of lesions which necessitate use of the device; and

· Type of unit to be dispensed and description of specific device features; and

· Consideration of less costly treatments; and

· Treatment plan.

High-pressure, rapid-cycling pneumatic compression devices (E0675), intermittent limb compression devices (E0676), and nonpneumatic, nonsequential, peristaltic wave compression pumps (E0683) are capped rental items only. Documentation must clearly articulate the expected length of need. Authorization will be made for up to three months at a time for E0675, E0676, and E0683, up to the total capped rental period. Subsequent requests must illustrate that the member has responded to treatment and continues to require treatment with the device.

Submit authorization requests and required documentation to the Medical Review Agent.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Bill compression devices using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifiers KH, KI, KJ, and RR for rentals.

· Use HCPCS code A4600 for appliance replacements for HCPCS code E0676.

· Do not bill integrated appliances in addition to other segmental pneumatic appliances.

Dispensing of compression devices and appliances include all accessories and education on use of equipment. Routing servicing and repairs are included in the payment for rentals.

Appliances and other supplies used with intermittent limb compression devices (E0676) are included in the payment for the pump.

Payment for HCPCS codes listed in Column 2 are included in payment for those in Column 1.

Column 1	Column 2
E0658	E0657, E0668
E0659	E0657
E0670	E0656, E0667