HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
E-9-014
Topic:
Non-Custom/Custom-Made Gradient Compression Garments/Stockings/Sleeves
Section:
Durable Medical Equipment
Effective Date:
November 19, 2017
Issued Date:
September 13, 2021
Last Revision Date:
August 2021
Annual Review:
August 2021
 
 

Gradient compression garments are stretch knit fabrics that are worn over an area of the body. They can be used to treat lymphedema and various venous stasis ulcers; to prevent clots; and/or to provide general comfort.

Custom-made gradient compression stockings are tailored to the specific individual's measurements.

Policy Position

Custom-made Gradient Compression Garments/Stockings/Sleeves

Custom-made gradient compression stockings/sleeves may be considered medically necessary when prescribed and documented by a health care provider (i.e., physician, physician assistant, or certified registered nurse practitioner) when ANY ONE of the following are met.

  • Failure for a prefabricated garment to fit properly; or
  • Failure to provide the therapeutic support (i.e., lost elasticity, tears, etc.); or 
  • Reinforced areas (e.g., heels) or zippers alone are not unique and do not constitute a custom garment; or
  • Documentation for diagnosis of obesity (BMI measurement not applicable); or
  • Documentation for diagnosis of venous insufficiency.

    AND

    When ALL of the following criteria are met:

    • A written, signed, and dated order must be received by the supplier before dispensing custom-made gradient compression stockings/sleeve; and
    • A qualified health care professional must document the clinical characteristic of the individual's affected area that is requiring a compression stockings/sleeve (i.e., physician, physician assistant, certified registered nurse practitioner, or nurse); and
    • Complete documentation of medical assessment and covered diagnosis.

    AND

    ANY ONE of the following:

  • Lymphedema; or
  • Burns (addressed separately below); or
  • Varicose veins (except spider veins); or
  • Chronic venous insufficiency; or
  • Venous stasis disease; or
  • Venous valvular insufficiency; or
  • Venous insufficiency; or
  • Post thrombotic syndrome; or

  • Venous ulcer (stasis ulcer), including ANY ONE of the following:

    • Edema; or
    • Venous; or
    • Lymph; or
    • Post traumatic; or
    • Post-surgical; or
    • Lipedema; or
    • Angiodysplasia; or
    • Prevention of thrombosis post-operatively; or
    • Post sclerotherapy; or
    • Documented thrombosis risk; or
    • Venous eczema; or
    • Lipodermatosclerosis.

  • Custom-made gradient garments will only be dispensed in the amount prescribed by the physician, physician assistant, or nurse practitioner.

    Replacement Custom-Made Gradient Compression Garments/Stockings/Sleeves
    Custom-made gradient compression garments/stocking/sleeve replacements, when replaced prior to six (6) months, are considered medically necessary when ANY ONE of the following are met:

    • Compression garment cannot be repaired (i.e., lost elasticity, tears, etc.); or
    • Changes in physical condition (e.g., change in size, unusual drainage, wear that weakened the support); and
    • A written, signed, and dated order must be received by the supplier before dispensing replacement custom-made gradient compression stockings/sleeve.
      .

ONLY six (6) individual (or three (3) pairs per individual for a total of three (3) pairs) of pressure gradient support garments/stockings/sleeves (in any combination i.e. knee-high, thigh-high etc.) will be dispensed at initial disbursement and every six (6) months thereafter. A pair is two (2) of the same items.

A yearly evaluation of an individual's condition must be performed to continue medical necessity for a custom fit garment. Evaluation is expected on a frequent basis (e.g., weekly) in a nursing facility or physician's office if there are heavily draining or infected wounds.

Any custom-made gradient compression garment/stocking/sleeve not meeting the criteria as indicated in this policy is considered not medically necessary.

A6549

 S8420

 S8422

 S8423

 S8425

 S8426

 S8429

S8430

 

 

 

 

 

 


Custom- Made Burn Compression Gradient Support Garments/Stockings/Sleeves

The following information is ONLY for those individuals with burn injuries and need custom-made compression gradient support garments/stockings/sleeves for management of edema, hypertropic scarring, and joint contractures.

Custom-made burn compression gradient support garments/stockings/sleeves may be considered medically necessary when ALL of the following criteria are met:

  • When prescribed and documented by a health care provider (i.e., physician, physician assistant, or certified registered nurse practitioner); and
  • A written, signed, and dated order must be received by the supplier before dispensing custom-made gradient compression stockings/sleeve; and
  • A qualified health care professional must document the clinical characteristic of the individual's affected area that is requiring a compression stockings/sleeve (i.e., physician, physician assistant, certified registered nurse practitioner, or nurse); and
  • Burns must be classified as ANY ONE of the following:
    • Second (2nd) degree burns; or
    • Third (3rd) degree burns.

ONLY eight (8) individual (or four (4) pairs) of custom-made burn compression gradient support garment/stockings/sleeves will be dispensed at initial disbursement and every three (3) months thereafter.

A custom-made burn compression gradient garment/stocking/sleeve is considered medically necessary and, therefore, covered when prescribed for the treatment and of burns in the management of the resulting edema, hypertrophic scarring and joint contractures following a burn injury.

Replacement of Custom-Made Burn Compression Gradient Support Garments/Stockings/Sleeves

Replacement of custom-made burn gradient compression support garments/stockings/sleeves, when dispensed prior to three (3) months, may be considered medically necessary when ALL of the following are met:

  • Pre-measuring for changes must be performed before a new prescription is issued; and
  • Documentation must support medical necessity; and
  • Medical record must support documented changes in physical condition (e.g., change in size, drainage amount increased, etc.); and
  • A written, signed, and dated order must be received by the supplier before dispensing replacements.

*Special Consideration for Replacements for Children – Burn Injuries Only

Due to continuous growth changes in infants and children, special consideration to replacement frequency will be given to those burn injury individuals, ages zero (0) to four (4) years of age, regarding significant increased replacement frequencies that require less than three (3) months for any custom-made burn compression gradient support garment replacement.

A yearly evaluation of an individual's condition must be performed to continue medical necessity for a custom fit garment. Evaluation is expected on a frequent basis (e.g., weekly) in a nursing facility or physician's office if there are heavily draining or infected wounds.

Any custom-made burn gradient compression garment/stocking/sleeve not meeting the criteria as indicated in this policy is considered not medically necessary. 

A6501

 A6502

 A6503

 A6504

 A6505

 A6506

 A6507

A6508

 A6509

 A6510

 A6511

 A6512

 A6513

 


Non-Custom-Made Gradient Compression Garments/Stockings/Sleeves

Non-custom-made gradient compression garments/stockings/sleeves may be considered medically necessary when ALL of the following are met:

  • The garments(s) must be specifically ordered and documented by a health care provider (i.e., physician, physician assistant, or certified registered nurse practitioner) caring for an individual; and
  • Documentation must support medical necessity; and
  • A written, signed, and dated order must be received by the supplier before dispensing non-custom-made gradient compression garment or stocking; and
  • A qualified health care professional must document the clinical characteristic of the individual's affected area that is requiring a compression stockings/sleeve (i.e., physician, physician assistant, certified registered nurse practitioner, or nurse).

AND

ANY ONE of the following:

  • Lymphedema; or
  • Varicose veins (except spider veins); or 
  • Chronic venous insufficiency; or
  • Venous stasis disease; or 
  • Venous valvular insufficiency; or 
  • Venous insufficiency; or 
  • Post thrombotic syndrome; or
  • Venous ulcer (stasis ulcer), including ANY ONE of the following:
    • Edema; or
    • Venous; or
    • Lymph; or
    • Post traumatic; or
    • Post-surgical; or
    • Lipedema.
  • Angiodysplasia; or
  • Prevention of thrombosis post-operatively; or 
  • Post sclerotherapy; or 
  • Documented thrombosis risk; or 
  • Venous eczema; or 
  • Lipodermatosclerosis.

Replacement of Non-Custom-Made Gradient Compression Garments/Stockings/Sleeves
Replacement of non-custom-made gradient compression garments/stockings/sleeves, when dispensed prior to six (6) months may be considered medically necessary when ALL of the following are met:

  • Pre-measuring for changes must be performed before a new prescription is issued; and
  • Documentation must support medical necessity; and
  • A written, signed, and dated order must be received by the supplier before dispensing replacement of non-custom-made gradient compression garment/stocking.

AND

ANY ONE of the following:

  • The compression garment cannot be repaired (i.e., lost elasticity, tears, etc.); or
  • Changes in physical condition (e.g., change in size, unusual drainage, wear that weakened the support).

ONLY six (6) individual (or three (3) pairs per individual for a total of three (3) pairs) of gradient compression garments/stockings/sleeves (in any combination i.e. knee-high, thigh high etc.)  per six (6) months can be dispensed. A pair is two (2) of the same items.

Any non-custom-made compression garments not meeting the criteria as indicated in this policy is considered not medically necessary.  

A6530

 A6531

 A6532

 A6533

 A6534

 A6535

 A6536

A6537

 A6538

 A6539

 A6540

 A6541

 A6544

 A6545

S8421

 S8424

 S8427

 S8428

 S8429

 S8430

 


Place of Service: Outpatient

Dispensing of non-custom/custom-made gradient compression garments/stockings/sleeves is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure 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.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.