Anthem Blue Cross Connecticut CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting Form

This document addresses the use of pneumatic compression devices for the prevention of deep vein thrombosis (DVT) of the extremities in the home setting. This therapy involves the use of an inflatable garment and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Pneumatic compression devices can be purchased or rented for home use for prevention and treatment of a number of conditions.

Note: This document addresses devices for the prevention of DVT only. Pneumatic devices used in the treatment or prevention of lymphedema, venous insufficiency, and therapy for musculoskeletal injuries are NOT addressed in this document. This document also does not address pneumatic compression devices with combined cooling or heating functions. For more information regarding such devices, please see the following related documents:

• CG-DME-06 Compression Devices for Lymphedema
• DME.00037 Cooling Devices and Combined Cooling/Heating Devices

Clinical Indications

Not Medically Necessary:

The use of pneumatic compression devices in the home setting for prevention of venous thromboembolism of the extremities is considered not medically necessary for all indications.