Pneumatic Compression Devices Form

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Pneumatic Compression Devices Medical Policy

Service: Pneumatic Compression Devices

PUM 250-0022-1812

Medical Policy Committee Approval
07/25/2024 Effective Date
08/01/2024 Prior Authorization Needed
Yes

NOTE: Pneumatic compression devices are often listed as an exclusion of the health plan. Please verify member benefits.

Description:

Pneumatic compression devices (also called intermittent compression devices [ICDs] or intermittent pneumatic compression pumps [IPCs]) consist of inflatable garments/wraps that are placed around an area of the body (such as legs) and pumps that provide alternating inflation and deflation to improve circulation.

Definitions:

*Immobilized, for the purpose of this policy, is the inability to ambulate (walk) due to trauma, surgery, or medical condition that requires prolonged complete bed rest or prevents any ambulation (i.e., inability to get out of chair/bed and walk to the toilet without the help of another person).

Indications of Coverage:

A. Home use of a single compartment (non-segmented) without calibrated gradient pressure or multi-chamber (segmented) without calibrated gradient pressure pneumatic compression devices are considered medically necessary for DVT prophylaxis strictly on the lower extremities ONLY in any of the following:

1. Hip fracture
2. Total hip replacement
3. Total knee replacement

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4. Deep vein thrombosis (DVT) prevention in an *immobilized individual

5. Postoperative DVT prevention in patients who have a contraindication to pharmacologic prophylaxis or at an increased risk of adverse events from pharmacologic prophylaxis.

   B. Single compartment or multi-chamber pneumatic compression devices without calibrated gradient pressure are considered medically necessary for the treatment of chronic or severe extremity lymphedema when all of the following are met:

6. The treating healthcare provider has documented that a 4-week conservative therapy trial failed to significantly improve symptoms*. The 4-week trial must have included all of the following:

   a) Compression garment or wrapping providing 30mmHG worn daily.
   b) Appropriate provider-recommended exercises performed daily.
   c) Affected limb elevated daily. d) A course of complete decongestive physiotherapy (manual lymph drainage) performed by a physical or occupational therapist, preferably certified in manual lymph drainage.

   *Any improvement with these services (1a—1d), either with improvement in symptoms, or decreased size/girth of the affected body part, is considered to be a positive response, and the Pneumatic Compression Device without calibrated gradient pressure will be considered not medically necessary. If there is no improvement over the most recent 4-week period, the Pneumatic Compression Device without calibrated gradient pressure may be considered medically necessary.

7. Affected limb continues to be symptomatic with any of the following: Pain, heaviness, decreased function, or recurrent skin infection

   C. Single compartment or multi-chamber pneumatic compression devices (with manual control of pressure, or calibrated pressure gradient pump), such as Flexitouch, are considered medically necessary for the treatment of chronic or severe extremity lymphedema, when all of the following are met:

8. The treating healthcare provider has documented that a 4-week conservative therapy trial failed to significantly improve symptoms*.

   The 4-week trial must have included all of the following:

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a) Compression garment or wrapping providing 30mmHG worn daily, prior to a trial of the pneumatic compression pump without calibrated gradient pressure. b) Appropriate provider-recommended exercises performed daily.
c) Affected limb elevated daily. d) A course of complete decongestive physiotherapy (manual lymph drainage) performed by a physical or occupational therapist, preferably certified in manual lymph drainage. e) A four-week trial of a pneumatic compression device without calibrated gradient pressure has failed to improve symptoms or lymphedema measurements, despite being used daily.

*Any improvement with these services (1a—1e), either with improvement in symptoms, or decreased size/girth of the affected body part, is a positive response, and the Pneumatic Compression Device with calibrated gradient pressure will be considered not medically necessary. If there is no improvement over the most recent 4-week period, to include continued use of the Pneumatic Compression Device without calibrated gradient pressure, the Pneumatic Compression Device with calibrated gradient pressure may be considered medically necessary.

2. Affected limb continues to be symptomatic with any of the following: Pain, heaviness, decreased function, or recurrent skin infection

   D. Single compartment or multi-chamber pneumatic compression devices without calibrated gradient pressure are considered medically necessary for the treatment of lower extremity venous ulcers, when all of the following are met:

   1. Individual is unable to use all other compression interventions.

   2. 6 months of prior treatment, which included compression stockings and/or compression leg wraps, and appropriate wound care treatment(s) have failed to heal the ulcer(s).

   3. Individual is not a candidate for other interventions (e.g., ablation of saphenous vein or sclerotherapy of superficial veins).

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Limitations of Coverage:

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be denied as experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be denied as not medically necessary.

D. Single compartment or multi-chamber pneumatic compression devices without calibrated gradient pressure pump, are considered not medically necessary unless all conservative management has failed to provide symptomatic relief or a decrease in the measured girth or size of the affected extremity/body part.

E. Single compartment or multi-chamber pneumatic compression devices with calibrated gradient pressure pump are considered not medically necessary unless all conservative management to include a 4-week trial of a pneumatic compression device (without calibrated gradient pressure pump) has failed to provide symptomatic relief or a decrease in the measured girth or size of the affected extremity/body part.

F. Intermittent pneumatic trunk compression for the prevention of thrombosis following orthopedic surgery will be denied as experimental, investigational, and unproven to affect health outcomes.

G. Pneumatic compression devices for any orthopedic procedure/surgery/condition other than those listed in the Indications of Coverage will be denied as not medically necessary.

H. Pneumatic compression devices will be denied as experimental, investigational, and unproven to affect health outcomes for any of the following (not an all- inclusive list, see Limitation of Coverage B. above):

1. Critical limb ischemia
2. Restless leg syndrome
3. Intermittent claudication

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4. Post-thrombotic syndrome

   I. Non-pneumatic compression devices, such as Dayspring are considered experimental, investigational, and unproven for lymphedema or any other indication.

   J. The use of chest, trunk, head or neck compression garments (appliances) with a pneumatic compression device in the treatment of lymphedema is considered experimental, investigational, and unproven.

   K. Use of pneumatic compression devices for Lymphedema of the Head and Neck is considered experimental, investigational, and unproven.

   L. Pneumatic compression device for prophylactic deep venous thrombosis after shoulder surgery is considered experimental, investigational, and unproven.

   Documentation Required:
   • Office, hospital, or procedure notes as applicable
   • Documentation of conservative therapy trial (for lymphedema)

   Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

   Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

                                                               Approved by the Medical Director

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Policy Review History:

Implemented
10/01/19, 01/01/21, 12/01/21, 12/01/22, 12/01/23, 08/01/24 Medical Policy
Committee Approval
06/21/19, 8/20/20, 08/26/21, 08/25/22, 08/31/23, 07/25/24 Reviewed

8/26/21, 07/05/22, 08/25/22, 04/01/23 (revised), 08/31/23, 07/25/24 Developed
06/21/19