K1033, Non-pneumatic sequential compression garment, half leg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- Single or multi-chamber or segmentnon-programmablecompression devices are consideredmedically necessarywhen the criteria below have been met:
- Treatment of upper or lower limb lymphedema;and
- The individualâs lymphedema is not improving;and
- The individual has been compliant with conservative therapy*.
- *Conservative therapy may include any combination of the following: elevation of the affected limb, exercise, massage, use of an appropriate compression bandage system or compression garment.
- Single or multi-chamber or segmentprogrammable(for example, calibrated gradient pressure) compression devices are consideredmedically necessarywhen the criteria below have been met:
2 Active Policies
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
ANTHEM-CG-DME-06, CG-DME-06 Compression Devices for Lymphedema
Related Codes
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