Medical Policy: 01.01.17
Original Effective Date: September 2009
Reviewed: November 2014
Revised: November 2014
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Pneumatic compression devices consist of an inflatable garment for the arm, leg, trunk, or chest and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.
There are 3 primary types of pumps:
- Single chamber (non-segmented) non-programmable pumps: These are the simplest pumps, consisting of single chamber that is inflated at one time that applies uniform pressure.
- Multi-chamber (segmented) non-programmable pumps: These pumps have multiple chambers, ranging from 2 to 12 or more. The chambers are inflated sequentially and have a fixed pressure in each compartment. They either have the same pressure in each compartment or a pressure gradient, but they do not include the ability to manually adjust the pressure in individual compartments.
- Single or multi-chamber programmable pumps: These are similar to the pumps described except it is possible to make manual adjustments in the pressure in the individual compartment and/or the length and frequency of the inflation cycles.
In general, a non-segmented or segmented compression device without manual control is considered sufficient to meet the needs of the individual. Typically, the only time a segmented, calibrated gradient pressure device would be indicated is when the individual has contractures, significant scarring, sensitive skin or another unique characteristic that prevents them from receiving satisfactory treatment from a non-segmented or segmented device without manual control. This policy addresses various conditions for which pneumatic compression devices have been investigated for use.
Lymphedema is caused by an abnormality of the lymphatic system leading to excessive build up of tissue fluid that forms lymph, known as interstitial fluid. Stagnant lymph fluid contains protein and cell debris that causes swelling of affected tissues. Left untreated, lymphedema leads to chronic inflammation, infection and hardening of the skin that, in turn, results in further lymph vessel damage and distortion of the shape of affected body parts.
Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema. Lymphedema is a condition that develops slowly and once present is usually progressive.
Lymphedema is divided into two broad classes according to etiology:
- Primary lymphedema is relatively uncommon and typically arises out of congenital anomalies or developmental abnormalities.
- Secondary lymphedema results from the destruction of or damage to formerly functioning lymphatic channels such as surgery for malignant tumors, removal of lymph nodes, post radiation fibrosis, and trauma.
Although the impact of arm/extremity lymphedema has been well studied and documented, very little attention has been focused on the impact of trunk (truncal) and chest edema. There is insufficient evidence that treating the truncal/chest area in addition to the limb affected by lymphedema improves the outcomes of pneumatic compression pump therapy more than only treating the limb. Further research is indicated and clinically meaningful reductions in truncal girth should also be defined.
Conservative measures for the treatment of lymphedema include, but are not limited to elevation of the affected limb, exercise, massage, and use of a compression bandage system or compression garment.
Chronic Venous Insufficiency With Venous Stasis Ulcers
Chronic venous insufficiency (CVI) of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.
Compression therapy remains the cornerstone of management for patients with chronic venous insufficiency, particularly those with venous ulceration. The goals of treatment are ulcer healing, reduction of edema, and improvement of pain. Prior to using compression therapy, it is important to confirm that the ulcer is due to chronic venous insufficiency rather than ischemia, or of mixed origin. Compression therapy is contraindicated in patients with peripheral artery disease.
Conservative measures for the treatment of venous stasis ulcers includes a compression bandage system or compression garment, appropriate dressings for the wounds, exercise, and elevation of the affected limb.
Single compartment or multichamber nonprogrammable pneumatic compression devices for the treatment of lymphedema may be considered medically necessary if:
- the patient has undergone a four-week trial of conservative therapy AND
- the physician determines there has been no significant improvement or if significant symptoms remain after the trial.
Single or multichamber programmable pneumatic compression devices may be considered medically necessary for the treatment of lymphedema when:
- The individual is otherwise eligible for nonprogrammable pumps; AND
- There is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable lymphedema pumps (e.g., significant scarring, contracture or highly sensitive skin).
The use of pneumatic compression devices to treat the trunk or chest in patients with lymphedema limited to the upper and/or lower limbs is considered investigational.
Based on the peer reviewed medical literature the role of trunk or chest pneumatic compression therapy in the treatment of lymphedema is lacking, the clinical effectiveness of these devices cannot be determined and their role in the management of lymphedema has not been established and further research is indicated.
Chronic Venous Insufficiency with Venous Stasis Ulcers:
Pneumatic compression devices (single chamber/nonsegmental) for the treatment of chronic venous insufficiency with ulcers may be considered medically necessary if:
- the patient has one or more venous stasis ulcers which have failed to heal after a six month trial of conservative therapy.
All other uses of pneumatic compression devices including but not limited to the following are considered investigational because the safety and/or effectiveness of these devices cannot be established by review of the available peer reviewed literature:
- Peripheral artery disease/arterial insufficiency
- Restless leg syndrome
- Management of edema following femoro-popliteal bypass surgery
- Rehabilitation for distal radial fracture
- Fracture and soft tissue healing
- Treatment of sensory impairment in the upper limb following a stroke
- Treatment of upper extremity vascular ulcers
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- E0650 Pneumatic compressor, nonsegmental home model
- E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure
- E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure
- E0655 Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
- E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk
- E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest
- E0660 Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
- E0665 Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
- E0666 Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg
- E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg
- E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm
- E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg
- E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
- E0671 Segmental gradient pressure pneumatic appliance, full leg
- E0672 Segmental gradient pressure pneumatic appliance, full arm
- E0673 Segmental gradient pressure pneumatic appliance, half leg
- E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)
- E0676 Intermittent limb compression device (includes all accessories), not otherwise specified
- Delis KT, Husmann MJ, Cheshire NJ, Nicolaides AN. Effects of intermittent pneumatic compression of the calf and thigh on arterial calf inflow: a study of normals, claudicants, and grafted arteriopaths. Surgery. 2001 Feb;129(2):188-95.
- Labropoulos N, Wierks C, Suffoletto B. Intermittent pneumatic compression for the treatment of lower extremity arterial disease: a systematic review. Vasc Med. 2002 May;7(2):141-8.
- Louridas G, Saadia R, Speay J, Abdoh A, et al. The ArtAssist Device in chronic lower limb ischemia. A pilot study. Int Angiol. 2002 Mar;21(1):28-35.
- Delis KT, Nicolaides AN. Effect of intermittent pneumatic compression of foot and calf on walking distance, hemodynamics, and quality of life in patients with arterial claudication: a prospective randomized controlled study with 1-year follow-up. Ann Surg. 2005 Mar;241(3):431-41.
- ECRI Institute. ArtAssist Intermittent Pneumatic Compression Device for the Treatment of Lower Extremity Arterial Disease. Plymouth Meeting (PA): ECRI Institute; 2005 Feb 23. 7 p. [ECRI hotline response].
- Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al.; American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC; AHA Task Force on Practice Guidelines; Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease; American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; Vascular Disease Foundation. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006 Mar 21;47(6):1239-312.
- Centers for Medicare & Medicaid Services (CMS). NCD for Pneumatic Compression Devices (280.6). Effective Date April 14, 2002. Accessed March 7, 2011. Rockson SG. Diagnosis and management of lymphatic vascular disease. J.Am.Coll.Cardiol. 2008;52:799-806.
- Dolibog P, Franek A, Taradaj J et al. A randomized, controlled clinical pilot study comparing three types of compression therapy to treat venous leg ulcers in patients with superficial and/or segmental deep venous reflux. Ostomy Wound Manage 2013; 59(8):22-30.
- National Lymphedema Network: Position Statement of the National Lymphedema Network for the Diagnosis and Treatment of Lymphedema. Available at www.lymphnet.org
- UpToDate. Prevention and Treatment of Lymphedema. Emile R. Mohler III, M.D., Tammy E. Mondry, DPT, MSRS, CLT-LANA. Topic last updated June 16, 2014. Also available at www.uptodate.com
- UpToDate. Compression Therapy for the Treatment of Chronic Venous Insufficiency. David G. Armstrong, DPM, M.D., PhD, Andrew J. Meyr, DPM. Topic last updated August 18, 2014. Also available at www.uptodate.com
- ECRI. Product Brief: Flexitouch System (Tactile Systems Technology, Inc.) for Treating Lymphedema. March 2014. Also available at http//:www.ecri.org
- MedScape. Lymphedema Treatment and Management. Updated April 22, 2014. Also available at http://emedicine.medscape.com
- Sheila H. Ridner, PhD, R.N., Barbara Murphy, M.D. et. al. Advanced Pneumatic Therapy in Self-Care of Chronic Lymphedema of the Trunk. Lymphatic Research and Biology, Volume 8, Number 4, 2010.
- PubMed. A Randomized Clinical Trial Comparing Advanced Penumatic Truncal, Chest, and Arm Treatment to Arm Treatment Only in Self-Care of Arm Lymphedema. January 2012. Also available at www.ncbi.nlm.nih.gov/pubmed
- PubMed. Intermittent Pneumatic Compression Fracture and Soft Tissue Injuries Healing. Also available at www.ncbi.nlm.nih.gov/pubmed
- PubMed. The Effect of Intermittent Pneumatic Compression on Fracture Healing. Also available at www.ncbi.nlm.nih.gov/pubmed
- PubMed. Cyclic Pneumatic Soft Tissue Compression Enhances Recovery Following Fracture of the Distal Radius: A Randomized Controlled trial. Also available at www.ncbi.nlm.nih.gov/pubmed
- PubMed. Use of Intermittent Pneumatic Compression for Treatment of Upper Extremity Vascular Ulcers. Also available at www.ncbi.nlm.nih.gov/pubmed
- PubMed. Treating Sensory Impariments in the Post Stroke Upper Limb with Intermittent Pneumatic Compression. Results of Preliminary Trial. Also available at www.ncbi.nlm.nig.gov/pubmed
- American Heart Association/American Stroke Association. Interventions for Sensory Impairment in the Upper Limb after Stroke. November 2010. Also availablbe at http://stroke.ahajournals.org/content/42/2/e18
- Alexander te Slaa, et. al. Prospective Randomized Controlled Trial to Analyze the Effects of Intermittent Pneumatic Compression on Edema Following Autologous Femoropopliteal Bypass Surgery. World Journal of Surgery (2011) 35:446-454
Date Reason Action
December 2010 Annual review Policy renewed
March 2011 Interim review Policy revised
February 2012 Annual review Policy renewed
February 2013 Annual review Policy renewed
January 2014 Annual review Policy revised
November 2014 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.