​​​Changes to medical policy on pneumatic compression therapy devices​

September 23, 2022

Effective October 24, 2022, Independence Blue Cross and Independence Administrators will update their medical policy on pneumatic compression therapy devices for both Commercial and Medicare Advantage members.

For Commercial members, the following criteria will be added to this policy as

Experimental/Investigational:

  • Lymphedema pumps applied to the head and neck to treat lymphedema

Face-to-face requirement language will be added for HCPCS codes:

  • E0650 Pneumatic Compressor, Non-Segmental Home Model
  • E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure
  • E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure
  • E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk
  • E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest
  • E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk

The following ICD-10 code will be added to this policy:

PNEUMATIC COMPRESSION APPLIANCES FOR LYMPHEDEMA EXTENDING INTO HEAD AND NECK

  • E1399 Durable medical equipment, miscellaneous

The following ICD-10 codes will be removed from this policy:

L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, L97.109, L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.208, L97.209, L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, L97.309, L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.408, L97.409, L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, L97.509, L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, L97.809 , L97.901, L97.902, L97.903, L97.904, L97.905, L97.906, L97.908, L97.909

For Medicare Advantage members, the following criteria will be added to this policy as Experimental/Investigational:

  • Lymphedema pumps applied to the head and neck to treat lymphedema

In accordance with Medicare, Face-to-Face Requirement language will be added per CMS Final Rule for the following HCPCS codes:

  • E0650 Pneumatic Compressor, Non-Segmental Home Model
  • E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure
  • E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure
  • E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk
  • E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest
  • E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk

The following ICD-10 code will be added to this policy:

PNEUMATIC COMPRESSION APPLIANCES FOR LYMPHEDEMA EXTENDING INTO HEAD AND NECK

  • E1399 Durable medical equipment, miscellaneous

The following ICD-10 codes will be removed from this policy:

L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, L97.109, L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.208, L97.209, L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, L97.309, L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.408, L97.409, L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, L97.509, L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, L97.809 , L97.901, L97.902, L97.903, L97.904, L97.905, L97.906, L97.908, L97.909

For more information, view the Commercial and Medicare Advantage policy notifications, which were published on September 23, 2022.​