E0659, Segmental pneumatic appliance for use with pneumatic compressor, integrated,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation that the individual has had axillary or pelvic region lymph nodes removed, damaged or irradiated (operative reports, radiation records, clinical notes).
- Documentation of presence of lymphedema (clinical assessment, circumferential limb measurements, water displacement measurements, clinical notes describing symptoms/signs).
- When BIS is requested, documentation that one of the qualifying clinical scenarios is present: developed lymphedema; at‑risk status (e.g., BMI > 30 documented in chart; postoperative infection documented); or undergoing breast cancer treatment (documentation of planned or ongoing mastectomy/axillary lymph node dissection or other breast cancer treatment).
- For BIS in breast cancer patients: documentation for 1) a one‑time preoperative baseline measurement (date and indication) and 2) postoperative monitoring dates and clinical rationale (postoperative monitoring may be up to 4 times in the first year of breast cancer treatment).
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.
- 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.)
- BIS is covered when the individual (who has had axillary or pelvic region lymph nodes removed, damaged, or irradiated) is at risk of developing lymphedema due to comorbidities (examples listed: excessive body weight with BMI greater than 30; postoperative infection). (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.)
- BIS is covered for individuals undergoing breast cancer treatment: BIS may be performed one time preoperatively to establish a baseline measurement for individuals who will be undergoing breast cancer treatment (including, but not limited to, mastectomy and axillary lymph node dissection); postoperative monitoring with BIS may be performed up to 4 times the first year of breast cancer treatment.
10 Active Policies
HUMANA-LYMPHEDEMA-DIAGNOSIS-AND-TREATMENT-MA, Lymphedema - Diagnosis and Treatment
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, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Related Codes
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