E0675, Pneumatic compression device, high pressure, rapid inflation/deflation cycle,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Applies only to pre-made or custom-made pressure gradient support stockings that have a pressure of 18 mm Hg or more, that require a physician's prescription, and that require measurements for fitting
- Physician's prescription is required for graded compression stockings (policy repeatedly notes requirement of a physician's prescription)
- Measurements for fitting are required for pre-made or custom-made pressure gradient support stockings
- Replacements are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member's physical condition (documentation should support unrepairable damage or change in physical condition)
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.
- Persons with lymphedema (see CPB 0069 - Lymphedema)
- Treatment of any of the following complications of chronic venous insufficiency: Varicose veins (except spider veins)
- Treatment of any of the following complications of chronic venous insufficiency: Venous edema
- Treatment of any of the following complications of chronic venous insufficiency: Venous ulcers (stasis ulcers)
- Treatment of any of the following complications of chronic venous insufficiency: Stasis dermatitis (venous eczema)
13 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-DME.00037, DME.00037 Cooling Devices and Combined Cooling/Heating Devices
UHC-POL-pneumatic-compression-devices, Pneumatic Compression Devices
AETNA-CPB-0482, Compression Garments for the Legs
AETNA-CPB-0500
Related Codes
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