E0659 — Segmental pneumatic appliance for use with pneumatic compressor, integrated, head, neck 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).
- Services that are reasonable and necessary for the diagnosis and treatment of lymphedema consistent with Medicare requirements and applicable NCDs/LCDs (Humana follows any applicable NCD/LCD/LCA for the jurisdiction).
- Bioimpedance Spectroscopy (BIS) (CPT 93702) will be considered medically reasonable and necessary for measurement of extracellular fluid volume when the individual has had axillary or pelvic region lymph nodes removed, damaged or irradiated.
- BIS is covered when the individual (who has had axillary or pelvic region lymph nodes removed, damaged, or irradiated) has developed lymphedema. (BIS may be performed up to 4 times per year for the first year after axillary or pelvic region lymph nodes were removed, damaged or irradiated.)
5 Active Policies
HUMANA-LYMPHEDEMA-DIAGNOSIS-AND-TREATMENT-MA — Lymphedema - Diagnosis and Treatment - Medicare Advantage
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
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