Pneumatic Compression Devices - DME.SW.101.A

Pneumatic compression devices (HCPCS E0650/E0651 basic, E0652 calibrated gradient, related codes E0655–E0673, with E0675 only for PAD and E0676 only for DVT prophylaxis) are covered only for specified indications: symptomatic lymphedema with documented skin changes/serial measurements and ≥4 weeks failed conservative care (E0652 required if lymphedema extends to chest/trunk/abdomen), venous insufficiency with leg ulcers after 6 months failed or intolerant compression, and immobile patients for DVT prevention when anticoagulation alone is inadequate. Coverage requires documentation matching the HCPCS code to the indication, medical records showing diagnosis, serial measurements/skin changes, and failure or intolerance of the specified conservative/compression therapies; devices not meeting these criteria are excluded.

"Basic pneumatic compression device (HCPCS E0650, E0651) is indicated when the individual has documented, symptomatic lymphedema and both: (a) documented skin changes or measurements have been taken..."