A4600, Sleeve for intermittent limb compression device, replacement only, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation note: DME coverage is for home use only; facility use not separately billable.
- Refer to Medical Policy DME101.000 (DME Introduction) for important information about DME coverage.
- Coverage determinations must include review of the member's benefit contract or Summary Plan Description (SPD) for coverage, exclusions, and limitations (e.g., dollar or duration caps).
- Procedure/service/supply/device codes listed are for reference only; presence or absence of codes does not determine coverage — rely on the written coverage position in the Medical Policy.
Key Coverage Criteria
- Pneumatic compression devices are medically necessary for the treatment of lymphedema or chronic venous insufficiency (CVI) with edema and non-healing lower extremity ulcers.
- For patients with lymphedema that has failed to respond to conservative measures, single-compartment or multi-chamber nonprogrammable pneumatic compression pumps applied to the limbs are medically necessary.
- Covered indication: For patients with lymphedema that has failed to respond to conservative measures, nonprogrammable pneumatic compression pumps applied to the limbs may be medically necessary. Additionally, single-compartment or multi-chamber programmable pneumatic compression pumps applied to the limbs may be medically necessary in similar scenarios where standard nonprogrammable pumps are inadequate or there is a need for programmable features.
- Pneumatic compression devices are covered in the home setting for treatment of lymphedema only after a four-week trial of conservative therapy (must include appropriate compression bandage or garment, exercise, and elevation) and the treating physician determines there is no significant improvement or significant symptoms remain.
- Programmable pumps with pulsatile features may be considered for patients who fail to respond to an initial trial of a nonprogrammable pump.
- Medically necessary for postsurgical home/place of residence use for VTE prophylaxis in individuals with a contraindication to pharmacologic agents after: (1) major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip fracture surgery) OR (2) major non-orthopedic surgery or other orthopedic procedures if the individual is at moderate or high risk of VTE.
12 Active Policies
ANTHEM-CG-DME-46, CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
UHC-POL-pneumatic-compression-devices, Pneumatic Compression Devices
BCBSIL-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
BCBSIL-MED202.073, Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Related Codes
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