E0676, Intermittent limb compression device (includes all accessories), not otherwise
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Inferred documentation items (from the text and cited trials/guidelines) that would support medical necessity: documentation of the clinical indication (e.g., trauma, recent orthopedic surgery, neurosurgery, acute ischemic stroke with restricted mobility, documented immobility such as inability to walk to the toilet without help),
- For CLI: documentation that the patient has severe or critical limb ischemia and is not a candidate for surgical revascularization (text: "non-revascularization-based therapies used to treat patients with severe or critical limb ischemia (CLI) who are not candidates for surgical revascularization").
- For lymphedema: documentation that intermittent pneumatic compression is being used as an adjunct to complex decongestive therapy (CDT), particularly where mobility or exercise is compromised.
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.
- In patients with acute ischemic stroke and restricted mobility, the guideline authors suggested the use of prophylactic-dose heparin or IPC devices (Grade 2B).
- CLOTS 3 trial finding: IPC is an effective method of reducing the risk of DVT and possibly improving survival in a wide variety of patients who are immobile after stroke.
- IPC devices have been used for thrombosis prophylaxis after total hip replacement (THR) and total knee arthroplasty (TKA) (various devices and configurations described).
- Intermittent pneumatic compression has been used as a modality to aid fracture and soft-tissue healing and as adjunct in rehabilitation (small/suggestive studies).
- Intermittent pneumatic compression has been used to treat or aid healing of venous leg ulcers and venous insufficiency (evidence mixed/limited).
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-DME.00037, DME.00037 Cooling Devices and Combined Cooling/Heating Devices
UHC-POL-pneumatic-compression-devices, Pneumatic Compression Devices
AETNA-CPB-0500, Intermittent Pneumatic Compression Devices
BCBSIL-MED202.060
Related Codes
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