CG-DME-57 Lower Extremity Pressure Gradient Compression Stockings

This policy addresses individually fitted, prescription lower-extremity gradient compression stockings. Coverage is medically necessary for an initial purchase of two pairs for individuals needing treatment of edema; venous stasis/varicose veins/other lower-extremity circulatory disorders; lipedema; lipodermatosclerosis; or lymphedema. Stockings are not covered if these criteria are not met, and replacements are limited to a total of up to four pairs in a 12-month period (more than four pairs per year are not medically necessary).

"An initial purchase of two (2) pairs (2 units) of individually fitted prescription lower extremity gradient compression stockings are consideredmedically necessaryfor individuals who require treatm..."

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