Pneumatic Compression Devices

The DME MACs are retiring the Pneumatic Compression Devices LCD (L33829) and related Policy Article (A52488) effective for claims with dates of service on or after November 14, 2024 due to existence of National Coverage Determination 280.6
10/03/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This is not a new LCD nor is it a revision to an LCD, therefore does not require comment and notice.

Revision Effective Date: 10/22/2023
SUMMARY OF EVIDENCE:
Added: Information related to arterial intermittent pneumatic compression
ANALYSIS OF EVIDENCE:
Added: Information related to arterial intermittent pneumatic compression
BIBLIOGRAPHY:
Added: Information related to arterial intermittent pneumatic compression
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments document (A59219)

Revision Effective Date: 06/07/2022
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: “At the end of the four-week trial, if there has been improvement of the lymphedema extending onto the chest, trunk and/or abdomen, then reimbursement for an E0652 is not justified. Where improvement has occurred, the trial of conservative therapy must be continued with subsequent reassessment at intervals at least a week apart. When and only when no significant improvement has occurred in the most recent four weeks and the coverage criteria above are still met, an E0652 is eligible for reimbursement.”


07/27/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates based on CMS direction as a result of the United States District Court, District of Columbia decision in Greenwald v. Becerra (Decided June 7, 2022)

Revision Effective Date: 06/07/2022
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: “At the end of the four-week trial, if there has been improvement, then reimbursement for a PCD is not justified. Where improvement has occurred, the trial of conservative therapy must be continued with subsequent reassessment at intervals at least a week apart. Only when no significant improvement has occurred in the most recent four weeks and the coverage criteria above are still met, may the lymphedema be considered unresponsive to conservative therapy, and coverage for a PCD considered.”
Removed: “At a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate.”


07/13/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates based on CMS direction as a result of the United States District Court, District of Columbia decision in Greenwald v. Becerra (Decided June 7, 2022)

Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
 Revised: “prescribing physician” to “treating practitioner”
Revised: “physician” to “practitioner”
 Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
 GENERAL:
 Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
 DOCUMENTATION REQUIREMENTS:
 Revised: “physician’s” to “treating practitioner’s”
 GENERAL DOCUMENTATION REQUIREMENTS:
 Revised: “Prescriptions (orders)” to “SWO”


02/20/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

Revision Effective Date: 01/01/2019
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
 Removed: All references to NCD 280.6
 Added: Clarifying language to four-week trial for lymphedema under Group I, clarifying language to Group III coverage, and clarifying language to PCD code selection section

Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION
REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Supplier manual reference under Miscellaneous
Removed: PIM reference under Appendices
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Removed: Links
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article

Revision Effective Date: 07/01/2016
Links for Sources of Information and Basis for Decision updated.

Revision Effective Date: 07/01/2016
Links for Sources of Information and Basis for Decision updated.

Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.

Revision Effective Date: 12/01/2015
Links for Sources of Information and Basis for Decision updated.

Revision Effective Date: 12/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Trial requirements to reference “no significant improvement” rather than “no further improvement” for lymphedema, CVI, and for lymphedema extending on to the chest, trunk and/or abdomen
Removed: Word “Any” from trial requirements for lymphedema of the chest, trunk and/or abdomen
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)

Revision Effective Date: 12/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: Explicit statement on E0675 non-coverage
Added: E0676 benefit exclusion reference in related Policy Article
Revised: Requirements for Four-Week Trial for Lymphedema
Revised: Requirements for Six-Month Trial for Chronic Venous Insufficiency
Revised: E0652 requirements
HCPCS CODES AND MODIFIERS:
Added: E0675 and E0676
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
Revised: Requirements for E0652
Added: E0675 to ACA 6407 requirements table

Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
DOCUMENTATION REQUIREMENTS:
Replaced: WOPD with ACA 6407 WOPD instructions
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Instructions for Equipment Retained from a Prior Payer
Revised: Standard Language Documentation verbiage for CMN
Added: Repair/Replacement section