Pneumatic Compression Devices (PCDs) - JD DME

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, including the treatments which have been tried and failed; and
4. The clinical response to an initial treatment with the device

• 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

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

Note: Listing only "unique characteristics" in medical record will result in denial

No policy guidance available for E0675. The beneficiary's medical record must support the item ordered is reasonable and necessary. Claims for these items may be adjudicated on a claim-by-claim basis. If denial received submit to appeals.

Claim lines billed without a SC, GA, GY, or GZ modifier will be rejected as missing information.