E0665 — Non-segmental pneumatic appliance for use with pneumatic compressor, full arm
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).
- A standard pneumatic compression device (HCPCS code E0650, E0651) and associated appliances (HCPCS code E0655, E0660, E0665-E0669, E0671-E0673) used in the home setting are considered medically necessary for EITHER of the following:
- - for the treatment of intractable lymphedema when there is failure of a four-week trial of conservative medical management including ALL of the following: > home exercise program > limb elevation > compression bandage or compression garment use
- - for the treatment of chronic venous insufficiency (CVI) with venous stasis ulcer(s) of lower extremities when BOTH of the following criteria are met: > The individual has received medically-supervised treatment of the ulcer(s) for at least 24 weeks using standard wound care treatment, including compression, wound dressings, exercise, and elevation of the limb. > Failure of the ulcer(s) to decrease in size or demonstrate improvement despite conventional therapy.
6 Active Policies
CIGNA-0354 — Compression Devices - (0354)
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
Related Codes
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