E0667, Segmental pneumatic appliance for use with pneumatic compressor, full leg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For repeat trigeminal neuralgia cryoanalgesia: documentation supporting prior benefit and that repeat procedure is at least 6 months after prior cryoanalgesia.
- For passive cold compression therapy as DME: clinical documentation supporting the need to control swelling, edema, hematoma, hemarthrosis and pain (i.e., reason for DME), and appropriate physician order for DME.
- When CPT/HCPCS coding is used, documentation must support that the procedure/code corresponds to an indication covered by this CPB (i.e., link diagnosis, procedure note, operative report or DME order to the covered indication).
- Any use of cryoanalgesia/cryoneurolysis for indications that the CPB lists as experimental/investigational should be supported by documentation if submitted, but the CPB considers these not medically necessary (i.e., documentation will not make them covered).
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.
- ICD-10 G50.0: Trigeminal neuralgia (covered if selection criteria are met)
- Use of CPT codes 64600 (destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch) and 64620 (destruction by neurolytic agent, intercostal nerve) when furnished for the indications listed in this CPB.
- Selected ICD-10 diagnoses may be covered when selection criteria are met (examples listed in the CPB include G50.0 Trigeminal neuralgia; various joint effusion/hemarthrosis/pain codes; edema and swelling codes; pain codes), noting coverage is diagnosis- and criteria-dependent.
- Cryoanalgesia for the temporary relief of pain due to chronic refractory trigeminal neuralgia (subject to Appendix selection criteria).
- Pre-operative, intra-operative, and post-operative cryoanalgesia for post-operative pain management related to the Nuss procedure (pectus excavatum repair).
16 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
AETNA-CPB-0297, Cryoanalgesia and Therapeutic Cold
CIGNA-0354, Compression Devices
Related Codes
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