A pneumatic compression therapy device functions as a pump to improve circulation. The device consists of an inflatable garment, usually for the arm, leg, and/or ankle, and an electric pump. The inflatable garment is intermittently inflated and deflated in a cycle of time and pressure. Pneumatic compression therapy devices are classified as non-segmented or segmented, with or without calibrated gradient pressure.

Pneumatic compression devices/lymphedema pumps and appliances for in-home use may be considered medically necessary when ALL of the following are met:

• When prescribed by a physician; and
• Has appropriate physician oversight (i.e., physician evaluation of the individual’s condition to determine medical necessity of the device, suitable instruction in the operation of the machine as to the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment).

Segmented or non-segmented pneumatic compression devices without calibrated gradient pressure for in-home use may be considered medically necessary for the treatment of ANY ONE of the following:

• Lymphedema treatment (pumps and appliances) of the arm or leg that has failed a four (4) week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include ALL of the following:
  • A compression bandage system or compression garment; and
  • Exercise; and
  • Elevation of the limb.

OR

• Chronic venous insufficiency (CVI) of the lower extremities with non-healing venous stasis ulcer(s) after a six (6) month trial of conservative therapy directed by the treating physician. The trial of conservative therapy must include ALL of the following:
  • A compression bandage system or compression garment; and
  • Appropriate dressings for the wound; and
  • Exercise; and
  • Elevation of the limb.

OR

In-home use of limb compression devices for the following indications may be considered medically necessary for ANY ONE of the following:

• Prevention of post-thrombotic syndrome; or
• Venous thromboembolism (VTE) prophylaxis after major orthopedic surgery (e.g. total hip arthroplasty, total knee arthroplasty, hip fracture surgery) in individuals with a contraindication to pharmacological agents, i.e., at high risk for bleeding; or
• VTE prophylaxis after major non-orthopedic surgery or non-major orthopedic surgery in patients who are at moderate or high risk of VTE (see Professional Statements and Societal Positions) with a contraindication to pharmacological agents, i.e., at high risk for bleeding.

In-home use of limb compression devices for VTE prophylaxis for the following conditions, are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

• After major orthopedic surgery for individuals without a contraindication to pharmacological prophylaxis; or
• After major non-orthopedic surgery or non-major orthopedic surgery, for individuals who are at moderate or high risk of VTE without a contraindication to pharmacological prophylaxis and in patients who are at low risk of VTE; or
• After all other surgeries.

A portable, intermittent, limb compression device (i.e. Vena Pro) is considered experimental/ investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

 In-home use of limb compression devices for VTE prophylaxis for periods longer than 30 days post-surgery is not medically necessary.

Pneumatic compression devices not meeting the criteria as indicated in this policy are considered not medically necessary. 

Segmented pneumatic compression therapy devices with calibrated gradient pressure may be considered medically necessary for in-home use when the following medical necessity criteria are met:

• The individual's medical condition has failed to respond to therapy using a segmented pneumatic compressor without calibrated gradient pressure with clear documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented device without manual control of the pressure in each chamber.

Segmented pneumatic compression therapy devices with calibrated gradient pressure not meeting the criteria as indicated in this policy are considered not medically necessary.  

The use of pneumatic compression devices for the treatment of lymphedema of the head, neck, chest or trunk, and/or the treatment of arterial insufficiency, is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Pneumatic Compression Devices are typically an outpatient service which is only eligible for coverage as an inpatient service in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.