CG-DME-06 Compression Devices for Lymphedema

This policy addresses home compression devices (lymphedema pumps) for lymphedema. Coverage is medically necessary only for single- or multi-chamber, segmental non-programmable devices to treat upper or lower limb lymphedema when the condition is not improving and the individual has been compliant with conservative therapy (elevation, exercise, massage, and/or compression bandage/garment). Not covered: any device when these criteria are not met; two-stage programmable systems (chest/trunk “preparatory” plus limb “drainage”); devices for lymphedema outside the extremities; and non-pneumatic, non-sequential peristaltic-wave devices.

"Single or multi-chamber or segmentnon-programmablecompression devices are consideredmedically necessarywhen the criteria below have been met:"

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