Description

Pneumatic compression pumps, also referred to as intermittent pneumatic compression (IPC) pumps, consist of inflatable garments and an electric pump that fills the garments with compressed air. The inflatable garments may be thigh high, calf length or for the foot only (foot pump). Periodically, the pneumatic compression pump inflates the garment chamber (or chambers) with a preset pressure to compress the leg and then deflates. This alternating inflation/deflation is thought to improve the flow of blood back to the heart, thereby decreasing the potential complications from poor circulation. The frequency of the periodic inflation/ deflation and the amount of pressure used may vary from one device to another.

Pneumatic compression pumps may be used for either the treatment of chronic venous insufficiency or for prevention of venous thromboembolism. These devices may also be used for the treatment of lymphedema. For information regarding pneumatic compression pumps for the treatment of lymphedema, please refer to Lymphedema – Diagnosis and Treatment Medical Coverage Policy.

Types of Pneumatic Compression Pumps/Garments

• unicompartmental, multicompartmental, with or without gradient pressure (programmable or nonprogrammable)
• advanced multicompartmental programmable
• high pressure rapid inflation
• ambulatory, portable, battery- powered or combination cold/compression devices

A unicompartmental (nonsegmented) device, as its name suggests, consists of a single inflatable chamber that exerts uniform pressure along the affected limb. A multicompartmental (segmented) device has multiple chambers in the garment that inflate and deflate in a sequential fashion. Both the unicompartmental and the multicompartmental devices may be controlled either with or without manual control of the amount of pressure used in the compartments (manual control is also referred to as gradient pressure).

An advanced multicompartmental programmable pneumatic compression device (formerly referred to as a two-stage multichamber programmable pneumatic compression device) operates similar to the principles of manual lymph drainage (treat the proximal areas first, which is theorized to prepare the distal areas for drainage). Examples of this type of pump include, but may not be limited to, the AIROS 6, AIROS 8, Flexitouch (Flexitouch Plus) or Lympha Press Optimal (Lympha Press Optimal Plus).

A variation of the multicompartmental pneumatic compression pump is the CircuFlow 5200 Sequential Compression Device, which combines intermittent pneumatic compression with a sustained gradient pressure. (Refer to Coverage Limitations section)

High pressure, rapid inflation pneumatic compression pumps have been proposed for treatment of peripheral arterial disease/arterial insufficiency. A significantly higher pressure is used than in the more standard types of pneumatic compression pumps, along with a much more rapid inflation/deflation cycle. Examples of this type of pump include, but may not be limited to, the ArtAssist, VascuComp 1-AI or VenaFlow Elite. (Refer to Coverage Limitations section)

Policy Information

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019

Notice

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

ActiveCare+SFT, Circul8 (Max or Pro), Cirona 6300, Cirona 6400, MAC system, PlasmaFlow, Triple Play VT DVT-EZ Home Care Kit, VenaPro and VenoWave

are all examples of ambulatory, portable, battery-powered intermittent pneumatic compression pumps. These devices are intended for one-time use (ie, for one individual; disposable after the individual’s use), are lightweight and either have a battery pack attached directly to the inflatable sleeve or are connected via lead wires to a small battery pack that can either be carried over the shoulder (like a purse) or attached to a belt, which allows them to be used while the individual is out of bed; they are proposed as an aid in compliance. (Refer to Coverage Limitations section)

The Dayspring Limb Compression System

is a device that has been proposed as an alternative treatment for venous insufficiency and venous stasis ulcers. Unlike pneumatic compression pumps, it does not use air to produce the compression, but rather uses a nickel-titanium shape-memory alloy to apply sequential gradient compression. The device is wearable (portable), programmable and battery powered, consisting of the controller and a garment (limb sleeve). It may also be referred to as a nonpneumatic compression controller. (Refer to Coverage Limitations section)

Another type of pump

combines intermittent pneumatic compression with cold or heat therapy. It includes an electronic module that controls treatment time, level of compression and temperature. The unit continuously cycles liquid through circumferential wraps for cold or heat therapy, even over large surface areas. This type of device has been proposed for use to manage pain and swelling after surgery or injury. Examples of this type of pump include, but may not be limited to, the Game Ready GRPRO 2.1, ThermoComp, Triple Play VT, VascuTherm and the VPULSE. (Refer to Coverage Limitations section)

For information regarding cold or heat therapy devices, please refer to Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy.

Coverage Determination

For information regarding coverage for compression pumps for the treatment of lymphedema, please refer to Lymphedema – Diagnosis and Treatment Medical Coverage Policy.

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019
Page: 4 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for a unicompartmental (nonsegmented) or multicompartmental (segmented) pneumatic compression pump without gradient pressure (manual control of the pressure in the chamber) (E0650, E0651) for the following indications:

• Absence of any contraindications; AND
• Initial approval, if criteria are met, is limited to a maximum of 90 days;

AND either of the following:

1. Chronic venous insufficiency of the legs with venous stasis ulcers after a 6 consecutive month trial of conservative treatment has failed to heal the venous stasis ulcer. Conservative treatment should include all of the following:
   • Appropriate dressings for the wound; AND
   • Compression bandage system or compression garment; AND
   • Elevation of the limb; AND
   • Exercise; OR
2. Prevention of deep vein thrombosis (DVT) for the individual who is unable to ambulate (walk) due to trauma, surgery that requires prolonged postoperative (after surgery) complete bed rest or other conditions that prevent any ambulation.

Pneumatic compression pumps are often used in conjunction with other DVT prophylaxis (e.g., low molecular weight heparin)Humana members may be eligible under the Plan for a unicompartmental (nonsegmented) or multicompartmental (segmented) pneumatic compression pump with gradient pressure* (manual control of the pressure) (E0652) when ALL of the following criteria are met:

• Absence of any contraindications; AND

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019
Page: 5 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Individual has undergone a 4 consecutive week trial of a unicompartmental or multicompartmental pump without manual control of the pressure in each chamber; AND
• The treating healthcare provider determines that there has been no improvement or symptoms remain; AND
• Submission of clinical documentation of compliance/adherence with use of the unicompartmental or multicompartmental pump without manual control of the pressure in each chamber as per the healthcare provider’s instructions/prescription;

AND ONE of the following:

1. Chronic venous insufficiency of the legs with venous stasis ulcers; OR
2. Prevention of DVT for the individual who is unable to ambulate (walk) due to trauma, surgery that requires prolonged postoperative (after surgery) complete bed rest or other conditions that prevent any ambulation.

*This would include the advanced multicompartmental programmable pumps (e.g., AIROS 6, AIROS 8, Flexitouch [Flexitouch Plus] or Lympha Press Optimal [Lympha Press Optimal Plus]) which are considered equally effective to standard segmented pneumatic compression pumps.

Continuation of Coverage

Pneumatic compression pumps are initially authorized for 90 days. Continued authorization is dependent upon clinical documentation submitted by the prescribing healthcare provider that demonstrates the following:

• Adherence with the use of the device as per the healthcare provider’s instructions/prescription; AND

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019
Page: 6 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Confirmation of clinical benefit (e.g., improvement in, or prevention in worsening of, the condition for which the device was prescribed)

Note: The criteria for pneumatic compression pumps are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for pneumatic compression pumps for any indications other than those listed above including, but may not be limited to:

• Arterial insufficiency; OR
• Peripheral arterial occlusive disease

All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for pneumatic compression pumps in the presence of any of the following contraindications:

• Acute deep vein thrombosis; OR
• Limb edema due to acute cellulitis

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the following pneumatic compression pump devices for any indication:

• A-V Impulse System foot pump; OR

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019
Page: 7 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

High pressure, rapid inflation pneumatic compression pumps (eg, ArtAssist, VascuComp 1-AI and VenaFlow Elite) These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the following pneumatic compression pump devices for any indication:

• Ambulatory, portable, battery-powered intermittent or combination intermittent and sustained pneumatic compression devices (eg, ActiveCare+SFT, Circul8 [Max or Pro], Cirona 6300, Cirona 6400, MAC system, PlasmaFlow, Triple Play VT DVT- EZ home care kit, VenaPro and VenoWave); OR
• Devices with a sustained gradient pressure while also delivering a higher, intermittent pneumatic compression including, but not limited to, the CircuFlow 5200 Sequential Compression device

These are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the Dayspring nonpneumatic compression system controller (with or without sequential calibrated gradient pressure) or garments for any indication. These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for combination cold or heat therapy/intermittent pneumatic compression devices (eg, Game Ready GRPRO 2.1, ThermoComp, Triple Play VT, VascuTherm and VPULSE). Therapy administered with these devices has not been proven to be any more efficacious than traditional

Pneumatic Compression Pumps Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0478-019
Page: 8 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.delivery of heat/cold (eg, ice packs, heating pads) and therefore these devices are considered convenience items.

Additional information about circulation conditions, including chronic venous insufficiency, deep vein thromboembolism and phlebitis may be found from the following websites:

Background

• American Heart Association
• National Library of Medicine

Medical Alternatives

Alternatives to pneumatic compression pumps include, but may not be limited to, the following:

• Prescription drug therapy
• Surgical intervention

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.