E0658 — Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled 'Medical Records Documentation Used for Reviews.'
- For medical necessity clinical coverage criteria, providers must reference and meet the InterQual® CP: Durable Medical Equipment, Pneumatic and other Powered Compression Devices criteria (the policy explicitly directs reviewers to InterQual for clinical criteria).
- Documentation should support the diagnosis and clinical scenario that meets InterQual criteria (e.g., documentation of lymphedema or CVI with edema and non-healing lower extremity ulceration, or documented DVT risk factors/indication for IPC prophylaxis) — where applicable per InterQual; the policy does not list additional specific paperwork requirements beyond this referral to InterQual and the general medical records documentation statement.
Key Coverage Criteria
- Pneumatic compression devices are considered proven and medically necessary in certain circumstances for the treatment of lymphedema when medical necessity clinical coverage criteria are met (see InterQual® CP: Durable Medical Equipment, Pneumatic and other Powered Compression Devices).
- Pneumatic compression devices are considered proven and medically necessary in certain circumstances for the treatment of chronic venous insufficiency (CVI) with edema and non-healing lower extremity ulcers when medical necessity clinical coverage criteria are met (see InterQual® CP: Durable Medical Equipment, Pneumatic and other Powered Compression Devices).
- Intermittent limb compression devices are considered proven and medically necessary in certain circumstances for the prevention of deep venous thrombosis (DVT) when the medical necessity criteria in the InterQual subset are met (see InterQual® CP: Durable Medical Equipment, Pneumatic and other Powered Compression Devices).
- Single or multi-chamber or segmentnon-programmablecompression devices are consideredmedically necessarywhen the criteria below have been met:
- Treatment of upper or lower limb lymphedema;and
- The individualâs lymphedema is not improving;and
5 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
ANTHEM-CG-DME-06 — CG-DME-06 Compression Devices for Lymphedema
UHC-POL-pneumatic-compression-devices — Pneumatic Compression Devices
UMR-POL-UMR-pneumatic-compression-devices — Pneumatic Compression Devices
Related Codes
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