Pneumatic and Nonpneumatic Compression Devices
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 may provide pneumatic and nonpneumatic compression devices and supplies:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.
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. Equipment and supplies include compressors, appliances, and gradient compression garments, stockings, sleeves, and bandaging supplies.
Covered Services
Codes: A4465, A4490, A4495, A4500, A4510, A6501-A6541, A6544-A6545, A6549-A6550, A6552-A6589, A6593-A6610, E0650-E0652, E0655-E0660, E0665-E0673, E0675-E0683
MHCP covers the following equipment:
MHCP covers one pneumatic or nonpneumatic compressor and appliances per five years when less intensive treatments have not been effective. 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. Only compressors approved by the U.S. Food and Drug Administration are covered.
Gradient compression garments are conforming, elastic, and wearable garments that provide compression. MHCP covers three units of daytime gradient compression garments per each impacted extremity every six months. Two units of nighttime garments per each impacted extremity are covered every two years.
Gradient compression wraps are adjustable, relatively inelastic, and allow for more targeted compression than garments.
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 if all of the following criteria are met:
Nonsegmental pneumatic compression devices (E0650) and segmental pneumatic compression devices without calibrated gradient pressure (E0651) are covered with authorization for treatment of lymphedema if all of the following criteria are met:
Conservative therapy for treatment of chronic venous insufficiency of the lower extremities and lymphedema includes:
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.
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 member’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. 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.
Compression burn garments are covered for members with burn injuries to reduce scarring and prevent infection and further injury. Compression burn garments are custom fabricated.
Compression bandaging supplies are covered for members who require additions or supplies to garments or wraps to protect against skin breakdown and enhance comfort and flexibility.
Nonelastic binders for extremities (A4465) are covered for members with lymphedema and require adjustable compression.
Surgical stockings (A4490, A4495, A4500, A4510) are covered for members with edema, varicose veins, or other medical conditions requiring compression. Surgical stockings must have at least 20 millimeters of mercury (mmHg) at the ankle to be considered therapeutic.
Items that are not otherwise specified, including those for compression burn garments (A6512), daytime-gradient compression garments (A6549), nighttime-gradient compression garments (A6519), gradient compression wraps (A6584), accessories for compression garments or wraps (A6593), and compression bandaging supplies (A6609) are covered if the member meets medical necessity criteria. HCPCS codes A6512, A6519, A6549, A6584, A6593, and A6609 should only be used when compression items are not described by more specific HCPCS codes mentioned in this MHCP Provider Manual section. Documentation must clearly indicate member’s diagnosis, medical necessity, description of the item, and pricing information. HCPCS codes A6512, A6519, A6584, A6593, and A6609 require authorization if the submitted combined charges are over $400. HCPCS code A6549 requires authorization for excess quantities.
Pneumatic and nonpneumatic compression devices, appliances, and supplies are not included in the per diem for members living in a nursing facility or the per diem for members living in an intermediate care facility for people with developmental disabilities (ICF/DD).
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:
Documentation for authorization requests must include:
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, appliances, and supplies 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.
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.
Integrated Appliances Table
Integrated appliances include payment for all impacted areas of the body. Payment for HCPCS codes listed in column 2 of the Integrated Appliances Table are included in payment for any of those listed in the same row as column 1.
Integrated Appliances Table
Column 1 | Column 2 |
E0658 | E0657, E0668 |
E0659 | E0657 |
E0670 | E0656, E0667 |
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