Pneumatic Compression Device

Policy No: 134
Date of Origin: 03/01/2018
Section: Administrative
Last Reviewed: 04/01/2024
Last Revised: 04/01/2021
Approved: 04/11/2024
Effective: 05/01/2024
Policy applies to: Group and Individual

This policy applies to all physicians, other health care professionals, hospitals and other facilities.

Durable Medical Equipment (DME):

DME is equipment that:

• Can withstand repeated use;
• Is primarily and customarily used to serve a medical purpose;
• Generally, is not useful to a person in the absence of an illness or injury; and

• Is appropriate for use in the home

All requirements of the definition must be met before an item can be considered durable medical equipment.

A Pneumatic Compression Device (PCD) is durable medical equipment.

A PCD is an electric or battery powered pump with attached inflatable appliances (sleeves) that fills with compressed air. As the appliance inflates, it applies compressive pressure gradient against the limb. The appliance is intermittently inflated and deflated to enhance the acceleration of blood flow through the limb.

Our health plan requires the use of the following PCD/appliance Healthcare Common Procedure Coding System (HCPCS) code combinations:

E0650: Pneumatic Compressor, Non-Segmental Home Model (For lymphedema or chronic venous insufficiency). Segmental gradient pressure pneumatic appliances (E0671, E0672, E0673) are appliances/sleeves which are used with non-segmented pneumatic compressor (E0650), but which achieve a pressure gradient through the design of the tubing and/or air chambers.

• E0655: Non-Segmental; Half Arm
• E0660: Non-Segmental; Full Leg
• E0665: Non-Segmental; Full Arm
• E0666: Non-Segmental; Half Leg
• E0671: Segmental; Full Leg
• E0672: Segmental; Full Arm

• E0673: Segmental; Half Leg

E0651: Pneumatic Compressor, Segmental Home Model without Calibrated Gradient Pressure (For lymphedema or chronic venous insufficiency)

• E0667: Segmental; Full Leg
• E0668: Segmental; Full Arm

• E0669: Segmental; Half Leg

E0652: Pneumatic Compressor, Segmental Home Model with Calibrated Gradient Pressure (For lymphedema or chronic venous insufficiency)

• E0656: Segmental; Trunk
• E0657: Segmental; Chest
• E0667: Segmental; Full Leg
• E0668: Segmental; Full Arm
• E0669: Segmental; Half Leg
• E0670: Segmental; Two Full Legs and Trunk
• E0671: Segmental; Full Leg
• E0672: Segmental; Full Arm

• E0673: Segmental; Half Leg

E0675: Pneumatic Compression Device, High Pressure, Rapid Inflation/Deflation Cycle, for Arterial Insufficiency (Unilateral or Bilateral System) (For Peripheral Artery Disease (PAD)

• E0667: Segmental; Full Leg
• E0668: Segmental; Full Arm

• E0669: Segmental; Half Leg

E0676: Intermittent Leg Compression Device (Includes all Accessories), Not Otherwise Specified (For Deep Vein Thrombosis (DVT) Prevention);

• Appliances/sleeves are included and not separately payable.

Postsurgical home use of an intermittent PCD (E0676) for the purpose of prevention of venous thrombosis (E0676) is not eligible for reimbursement.

PCD devices which include cold therapy are not eligible for reimbursement.

When a PCD is determined to be ineligible for reimbursement, all related appliances and accessories are also ineligible for reimbursement.

NOTE: Use of a PCD in a facility (i.e., Ambulatory Surgery Center (ASC) is not eligible for reimbursement as it is included in the facility fee for the procedure(s); as such not separately allowable billed by the facility or a DME supplier.

Center for Medicare & Medicaid Services (CMS), HCPCS Level II codes

Non-Reimbursable Services