Prior Authorization for Pneumatic Compression Devices

The CMS final rule 42 CFR §§405 and 414., in 2016, established a Prior Authorization (PA) process for certain DMEPOS that are frequently subject to unnecessary utilization. CMS announced a nationwide expansion on April 13, 2026, to include Pneumatic Compression Devices (PCD) HCPCS codes E0651 and E0652.

Prior Authorization Timelines

Policy Initial Review Decision Timeframe Expedited Review Decision Timeframe PAR Decision Valid
PCD 5 business days (not to exceed 7 calendar days) 2 business days 60 days

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HCPCS Requiring Prior Authorization (PA)

E0651 - Pneumatic compressor, segmental home model without calibrated gradient pressure.

E0652 - Pneumatic compressor, segmental home model with calibrated gradient pressure.

Documentation to Include in PA Package Submission

  • PCD PA request coversheet
  • Standard Written Order
  • Medical record documentation to support coverage criteria
  • Documentation must be submitted to the appropriate jurisdiction based on the beneficiary's permanent address with the PA coversheet for fax, mail, or electronic submission of medical documentation (esMD). For Noridian Medicare Portal (NMP) submissions, complete all required fields in the portal as a coversheet is not required.

To ensure process efficiency, assure all components are completed and included within the submission.

PA requests for PCD will be reviewed within five business days.

Methods of Submission

Expedited Request Guidelines

In very rare emergent circumstances, an expedited review may be requested. An expedited request is when the five-day review timeframe for a PA decision could jeopardize the life or health of a beneficiary.

To be processed as an expedited request, ensure the following information is provided.

  • Request must be accompanied by medical documentation to support above requirements
  • On coversheet, indicate that it is an expedited request and provide justification in one or two sentences
  • To prevent delays, it is recommended to use the Noridian Medicare Portal (NMP), fax, or esMD when submitting expedited requests.

When a request supports the above guidelines, the DME MAC will make reasonable efforts to communicate a decision within two business days of the receipt of the expedited request.

Tips to Prevent an Expedited Request

  • Work with referral sources to establish the necessity of an item prior to an immediate need.
  • Discharge planning begins on admission to an acute care facility. Gather necessary documentation prior to day of discharge to prevent delays.

When documentation does not support the above guidelines, expedited requests will be downgraded to standard requests.

Avoid Request Rejection

There are various reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet or information not entered in portal and a thorough intake process aids in minimizing most rejections. Common reasons include:

  • HCPCS code is not subject to prior authorization
  • Duplicate to a previous PA request
  • The beneficiary does not reside in this jurisdiction based on the beneficiary's permanent address

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter.

When applicable, the prior authorization decision and corresponding claim information may remain with the beneficiary (i.e., the prior authorization decision identified via a Unique Tracking Number, or UTN, may transfer between suppliers and jurisdiction). CMS assumes such transfers would be made in accordance with applicable privacy laws.

Affirmative

Based on the review, it was determined the beneficiary meets the medical necessity requirements established by Medicare for the PCD requested.

Process:

  • Deliver PCDs and obtain Proof of Delivery
    • The affirmation decision is valid for 60 days from the date on the decision letter.
    • If the item is not delivered within 60 days, a new PA request must be submitted.
  • Bill with correct Unique Tracking Number (UTN) located in decision letter
  • Bill with appropriate ICD-10 code

Once an affirmed decision has been made, submit the claim. Include the 14-byte UTN, provided within the decision letter, as indicated below.

  • If billing on CMS-1500 Claim Form, include UTN in Item 23
  • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1)
  • Continue to bill with the UTN if billing as a rental.

Non-Affirmative

Based on the review, a supplier is required to follow-up prior to submitting a resubmission.

Options:

  • Review decision and submit a PA resubmission
    • Gather missing and/or clarifying documentation and resubmit
    • Able to submit unlimited resubmissions
  • Deliver PCDs and submit claim for denial
    • Execute Advance Beneficiary Notice of Non-coverage (ABN) prior to delivery, if appropriate
  • Do not deliver or bill

Decision Letters

Treating practitioners involved in the submission of a prior authorization may request a copy of the decision letter.

  • Treating practitioner requesting the letter must be able to demonstrate a legitimate, specific need for information requested
  • Request may be sent in with PA request or separately

Tips

General Coverage Criteria (E0651, E0652)

  1. The patient's diagnosis and prognosis.
  2. Symptoms and objective findings, including measurements which establish the severity of the condition.
  3. The reason the device is required is that it includes the treatments which have been tried and failed; and
  4. The clinical response to an initial treatment with the device

PCD Lymphedema Four-Week Trial (E0651, E0652)

  • Compliant use of compression bandage or garment
    • Adequate compression
    • Sufficient pressure
    • Prefabricated or custom fabricated
    • Graduated compression
  • Regular exercise
  • Elevation of limb
  • Initial treatment of PCD must be documented on or before date of delivery by clinician
    • Includes measurements
    • Must be part of medical record
    • Signed by treating practitioner, includes concurrence for LCMP records

PCD - E0652

  • Meets general coverage criteria
  • Meets at least a four-week Trial
  • The individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a non-segmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber.

Note: The documentation should include a description of the unique characteristics. Listing only "unique characteristics" in the medical record will result in denial.

Still Have Questions?

Call the Supplier Contact Center or Interactive Voice Response (IVR).

Resources

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