*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare^SM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Lymphedema is swelling of the subcutaneous tissue caused by an abnormal collection of fluid beneath the skin resulting from lymph vessel impairment or lymph node removal. It is generally categorized as primary or secondary. Primary lymphedema is caused by problems with the development of lymph vessels, while secondary is related to something that has damaged the lymph nodes or vessels (eg, surgery, radiation, cancer, infection). Lymphedema differs from edema which is swelling caused by excess fluid that becomes trapped in the body’s tissues as a result of medication, pregnancy or underlying disease (eg, heart failure, venous insufficiency, kidney disease, cirrhosis of the liver).

Policy Statement

Coverage will be provided for Pneumatic Compression Pumps when it is determined to be medically necessary when the medical criteria and guidelines shown below are met.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination.  Coverage will be approved according to the EOC limitations if the criteria are met. 

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (EOC), the EOC always governs the determination of benefits.

Indications for Coverage

This Policy will speak to the use of Pneumatic Compression devices for treatment of the chest, trunk and/or abdomen as standalone treatment (not in conjunction with limb treatment).

1. The use of lymphedema pumps and appliances to treat the trunk or chest is limited to individuals with:
   1. Lymphedema beyond the upper and lower extremities; and
   2. Have failed conservative therapy**; and
   3. Have failed therapy with lymphedema pumps and appliances to the upper and lower extremities only

When Coverage Will Not Be Approved

The use of lymphedema pumps to treat the trunk or chest in patients with lymphedema with or without involvement of the upper and/or lower limbs is considered investigational.

**The use of lymphedema pumps applied to the head and neck to treat lymphedema is considered investigational.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes.  Inclusion of a code in the section does not guarantee reimbursement. 

Applicable codes: E0650, E0651, E0652, E0656, E0657, E0660

The Plan may request medical records for determination of medical necessity.  When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Special Notes

Pneumatic compression devices are covered as a treatment of last resort; for example, other more conservative treatments must have been tried first and found to be inadequate. Such treatments would include leg or arm elevation and custom fabricated gradient pressure stockings or sleeves.

A segmented pneumatic compression device with manual control of the pressure in each chamber (HCPCS code E0652) is considered medically necessary only when the patient has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented compression device without manual control of pressure in each chamber.  Such conditions include significant scarring, sensitive skin or the presence of contracture with documentation of the need for a specified pressure to a localized area.  In addition, the criteria above must be met.

References:

1. Centers for Medicare and Medicaid Services(CMS) National Coverage Determinations(NCD) Pneumatic Compression Devices (280.6); effective date 1/14/2002 via NCD - Pneumatic Compression Devices (280.6) accessed on 8/21/2025
2. Centers for Medicare and Medicaid Services(CMS) National Coverage Determinations(NCD) Durable Medical Equipment Reference List (280.1); effective date 06/09/2025 via NCD - Durable Medical Equipment Reference List (280.1) accessed on 8/21/2025
3. Blue Cross NC Corporate Medical Policy: Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers; Originated on 6/1994 accessed via Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | Providers | Blue Cross NC on 8/15/2025

Policy Implementation/Update Information:

Revision Dates:

September 18, 2025, Newly created policy in the absence of CMS guidance on the use of a PCD for chest, trunk or abdomen as stand alone treatment.

Approval Dates:

Medical Coverage Policy Committee: September 18, 2025

Physician Group Advisory/UM Committee:

Quality Improvement Committee:

Policy Owner:  Amy Russo, LPN
Medical Policy Coordinator