E0658, Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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.
- 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
- The individual has been compliant with conservative therapy*.
- *Conservative therapy may include any combination of the following: elevation of the affected limb, exercise, massage, use of an appropriate compression bandage system or compression garment.
10 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
BCBSIL-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
BCBSMT-MED202.060
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