E0677, Non-pneumatic sequential compression garment, trunk
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- For lymphedema: documentation of 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 CVI with venous stasis ulcers: documentation that 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, elevation), and documentation of failure of the ulcer(s) to decrease in size or demonstrate improvement despite conventional therapy.
- For E0652 (calibrated gradient pressure device): documentation that the individual meets the standard pneumatic device criteria AND EITHER documented failure of relief with standard pneumatic compression device OR documentation that the individual requires specified pressure to a localized area.
Key Coverage Criteria
- 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.
- A pneumatic compression device with calibrated gradient pressure (HCPCS code E0652) and associated appliances (HCPCS code E0656-E0657, E0667-E0670) used in the home setting are considered medically necessary when BOTH of the following criteria are met: - individual meets above criteria for a standard pneumatic compression device - EITHER of the following: > documented failure of relief with standard pneumatic compression device > individual requires specified pressure to a localized area
- Continuation of use of a pneumatic compression device is considered medically necessary when BOTH of the following criteria are met: - there is adherence with the use of equipment as ordered by the healthcare professional - clinical documentation from the health care professional confirms clinical improvement (e.g., improvement in venous stasis ulcers, decrease in edema or lymphedema)
- HCPCS codes considered medically necessary when criteria are met: E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673
9 Active Policies
HUMANA-LYMPHEDEMA-DIAGNOSIS-AND-TREATMENT-MA, Lymphedema - Diagnosis and Treatment
ANTHEM-CG-DME-06, CG-DME-06 Compression Devices for Lymphedema
BCBSIL-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
BCBSMT-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
BCBSNM-MED202.060, Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Related Codes
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