Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Compression Garments

Policy #:05.00.37f

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

REQUIREMENTS FOR COVERAGE OF COMPRESSION GARMENTS

BURN GARMENTS
A compression burn garment (Healthcare Common Procedure Coding System [HCPCS] codes A6501-A6513) is considered medically necessary and, therefore, covered when prescribed for the treatment of burns to reduce the resulting hypertrophic scarring and joint contractures following a burn injury.

GARMENTS FOR UPPER EXTREMITY LYMPHEDEMA (GRADIENT PRESSURE AIDS, NON-ELASTIC BINDERS, AND MASTECTOMY SLEEVES)
A gradient pressure aid (e.g., a glove or gauntlet) (HCPCS codes S8420-S8429) or a non-elastic binder (e.g., ReidSleeve Classic Arm, CircAid JuxtaFit Essentials Armsleeve, ArmAssist) (HCPCS code A4465) is considered medically necessary and, therefore, covered when prescribed as part of a complete decongestive therapy (CDT) program for individuals with intractable lymphedema.

A mastectomy sleeve (HCPCS code L8010) is considered medically necessary and, therefore, covered when prescribed as part of a post-mastectomy comprehensive CDT program.

GRADIENT COMPRESSION STOCKINGS, NON-ELASTIC GRADIENT COMPRESSION WRAPS, AND NON-ELASTIC BINDERS FOR THE LOWER EXTREMITIES
Gradient compression stockings (e.g., Jobst stockings) (HCPCS codes A6530-A6541, A6544, A6549), non-elastic gradient compression wraps (e.g., Circaid Juxta-Lite™) (HCPCS code A6545), or non-elastic binders (e.g., CircAid JuxtaFit Essentials Standard Legging, LegAssist, Reid Sleeve Classic Leg)(HCPCS code A4465) are considered medically necessary and, therefore, covered when they are prescribed by a physician to treat conditions including, but not limited to, chronic venous insufficiency and lymphedema, and to prevent and treat venous stasis ulcers.
  • Limitations of coverage for gradient compression stockings are as follows: Coverage is limited to 12 individual gradient compression stockings (or six pairs of stockings if the individual requires the stockings for both lower extremities) (HCPCS codes A6530-A6541, A6544, A6549) within a calendar year. Additional stockings are considered not medically necessary and, therefore, not covered.
  • Limitations of coverage for gradient compression wraps (HCPCS code A6545) are as follows: Coverage is limited to one below-the-knee-gradient compression wrap per limb per six months. Additional wraps are considered not medically necessary and, therefore, not covered.

NIGHTTIME COMPRESSION GARMENTS FOR LYMPHEDEMA
For individuals with intractable lymphedema requiring nighttime compression, a second garment that is different from the garment used during the daytime may be considered medically necessary and, therefore, covered. Documentation must support the clinical rationale for the second garment with factors that include but are not limited to the following:
  • The daytime compression garment is not clinically appropriate for the management of the individual's lymphedema during the nighttime (e.g., daytime garment has elastic properties that provide too much compression for when the individual is sedentary/asleep).
  • The individual is unable to independently apply compression bandaging and does not have a caregiver to assist with compression bandaging.

COMPRESSION GARMENTS FOR THE TRUNK OR CHEST
Compression garments for the treatment of lymphedema in regions of the trunk or chest (e.g., JoVi Vest) (HCPCS code A9999) are considered medically necessary and, therefore, covered as part of a complete decongestive therapy (CDT) program (e.g., manual lymphatic drainage [MLD], skin care, lymphatic
exercise).

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic deterrent [TED]) stockings (HCPCS codes A4490-A4510) are considered medically necessary and, therefore, covered when they are used to prevent and/or treat conditions such as, but not limited to, deep vein thrombosis.
  • Limitations of coverage for antiembolism stockings are as follows: Coverage is limited to 12 individual antiembolism stockings (or six pairs of stockings if the individual requires the stockings for both lower extremities) (HCPCS codes A4490-A4510) within a calendar year. Additional stockings are considered not medically necessary and, therefore, not covered.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

In order to address excess edema and allow for proper fitting of gradient compression stockings, an individual may first require treatment with ambulatory low-stretch bandages or Unna boot variants.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, compression garments are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

MANDATES

This policy is consistent with applicable mandates and coverage requirements. The Women's Health and Cancer Rights Act of 1998 and individual state mastectomy coverage laws require coverage for all treatment of the physical complications resulting from mastectomy (including lymphedema).

Description

Compression garments are typically two-way stretch knit fabrics that are worn over an area of the body. They can be used to treat burns, lymphedema, or various venous stasis ulcers; to prevent clots; and/or to provide general comfort. The stretch and resistance of the garments, together with the natural movement of muscles and blood vessels during normal activity, help with circulation and increase the effectiveness of lymphatic vessels, thus reducing edema and pain.

Compression garments are available and prescribed to be used for specific parts of the body (e.g., glove-to-axilla, foot-to-knee, or upper/lower trunk), and stockings are available in varying pressures and lengths (e.g., waist length, thigh length, full length, and below-the-knee).

TYPES OF COMPRESSION GARMENTS

BURN GARMENTS
Compression burn garments (e.g., bodysuits and leotards) help burns to heal with less scarring by applying pressure and flattening the burn area. They also protect the skin, promote circulation within the damaged tissues, and decrease pain and itching.

LYMPHEDEMA GARMENTS
Garments used to control the excessive accumulation of lymphatic fluid in an upper extremity include gradient pressure aids (gloves and gauntlets) and mastectomy sleeves.

GRADIENT COMPRESSION STOCKINGS
Gradient compression stockings (e.g., Jobst [BSN-JOBST, Inc., Charlotte, NC]) can be used to treat chronic venous insufficiency and lymphedema and to prevent and treat venous stasis ulcers. These stockings deliver pressure to the leg that is tightest at the ankle, with the amount of compression gradually decreasing as the stocking moves up the leg. Gradient compression stockings are available in a variety of pressure levels (e.g., 20-30 mmHg, 30-40 mmHg).

NON-ELASTIC GRADIENT COMPRESSION WRAPS
Gradient compression wraps work in a similar manner as, and can be an alternative to, gradient compression stockings. These garments are non-elastic and are used in the treatment of open venous stasis ulcers and lymphedema. An example of a gradient compression wrap is the Circaid Juxta-Lite (CircAid Medical Products, Inc., San Diego, CA), which is a garment composed of a series of adjustable bands, allowing the individual to modify the pressure level as needed.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic deterrent [TED]) stockings are typically used for individuals during a hospitalization that requires bed confinement or during a postsurgery recuperation period. These stockings can also be used to help prevent leg fatigue and the discomfort associated with varicose veins. Antiembolism stockings offer equalized compression throughout the stocking, while gradient compression stockings offer graduated pressure throughout the stocking. Antiembolism stockings do not require a physician's prescription and can be purchased over the counter.

NON-ELASTIC BINDERS
Non-elastic binders are composed of material that is fastened with adjustable velcro, hooks, loops, or other straps to provide compression. They apply a gentle gradient compression to the extremity, with some models equipped with gauges that assess the applied pressure over the upper or lower extremity. The gauges provide the assurance that the amount of compression is consistently applied across the extremity. Non-elastic binders are used in the treatment of conditions that include lymphedema and chronic venous insufficiency. Examples include CircAid JuxtaFit Essentials (CircAid Medical Products, Inc., San Diego, CA); ArmAssist and LegAssist (BiaCare, Zeeland, MI); and ReidSleeve Classic Arm and ReidSleeve Classic Leg (Peninsula Medical, Inc., Scotts Valley, CA).

NIGHTTIME COMPRESSION GARMENTS FOR LYMPHEDEMA
Individuals with more severe forms of lymphedema may require compression during the day and at nighttime to effectively manage their lymphedema. Some daytime garments, particularly those with elastic components, are utilized when the individual is active and can provide too much compression at times when the individual is sedentary or asleep. An option for the nighttime management of lymphedema is compression bandaging; however, for individuals who have difficulty applying the bandaging or do not have assistance from a caregiver, a garment such as those with non-elastic components (e.g., Reid sleeve Classic Leg) may be an alternative.
COMPRESSION GARMENTS FOR THE TRUNK AND CHEST
Other compression garments that are commercially available include those for the treatment of lymphedema of the trunk and chest. An example is the JoVi Vest (JoVi PAK, Kent, WA). According to the manufacturer, the JoViVest is offered as a made-to-order or custom-fabricated garment and can be prescribed to address chest wall edema and fibrosis. For truncal and chest edema, manual lymphatic drainage (MLD), performed by an experienced professional provider, is a generally accepted standard medical practice, often followed by compression garments as part of complete decongestive therapy (CDT) program.
References


Agency for Healthcare Research and Quality (AHRQ). Technology Assessment: Diagnosis and Treatment of Secondary Lymphedema. [Centers for Medicare and Medicaid Services Web site]. 05/28/2010. Available at:
http://www.cms.hhs.gov/determinationprocess/downloads/id66aTA.pdf. Accessed May 14, 2018.

American Cancer Society (ACS). Women's Health and Cancer Rights Act. [ACS Web site]. 09/18/12. Available at: https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/health-insurance-laws/womens-health-and-cancer-rights-act.html. Accessed May 14, 2018.

BSN-JOBST. Products. [Jobst Web site]. Available at: http://www.jobst-usa.com/en/products/page.html. Accessed Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 270.5: Porcine skin and gradient pressure dressings. [CMS Web site]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAQAAAAAAA&. Accessed May 14, 2018.

CircAid Medical Products, Inc. Products. [Circaid Medical Products Web site]. 2012. Available at: http://www.circaid.com/products. Accessed May 14, 2018.

Company Benefit Contracts.

European Wound Management Association (EWMA). Lymphoedema bandaging in practice. 2005. Medical Education Partnership. [EWMA Web site]. Available at:
http://www.woundsinternational.com/media/issues/214/files/content_179.pdf. Accessed May 14, 2018.

Howell D, Ezzo J, Bily L, Johansson K. Complete decongestive therapy for lymphedema following breast cancer treatment (Protocol). The Cochrane Database of Systematic Reviews. 2009;1. [The Cochrane Library Web site]. Available at: http://www.thecochranelibrary.com [via subscription only]. Accessed May 14, 2018.

International Society of Lymphology (ISL). 2013 consensus document of the International Society of Lymphology: the diagnosis and treatment of peripheral lymphedema. [ISL Web site]. 2013. Available at: http://www.u.arizona.edu/~witte/2013consensus.pdf. Accessed May 14, 2018.

JoviPak. JoviVest. [JoViPak Web site]. 2013. Available at:http://jovipak.com/products/upper-body/vests. Accessed May 14, 2018.

Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. London: MEP Ltd, 2006. Available at: file:///C:/Users/ibx9403/AppData/Local/Microsoft/Windows/INetCache/IE/9IOP317Y/content_175.pdf. Accessed May 14, 2018.

National Lymphedema Network (NLN). Position statement of the National Lymphedema Network.Diagnosis and treatment of lymphedema. [NLN Web site]. 11/2013. Available at: https://www.lymphnet.org/pdfDocs/nlnexercise.pdf.Accessed May 14, 2018.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33317 External Breast Prostheses. Revised Effective 01/01/2017. Original effective: 10/01/2015. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/External+Breast+Prostheses/21376e51-3234-486a-8cc5-ec4a3b766e97. Accessed May 14, 2018.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33831 Surgical Dressings. Revised Effective 07/24/2017. Original effective: 10/01/2015. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Surgical+Dressings+LCD+and+PA/202d2835-2c25-4388-82b0-e74d280e137f. Accessed May 14, 2018.

O'Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers (Review). The Cochrane Database of Systematic Reviews.2009;1. [The Cochrane Library Web site]. Available at: http://www.thecochranelibrary.com [via subscription only]. Accessed May 14, 2018.

Peninsula Medical, Inc. The Reid sleeve classic. [Peninsula Medical, Inc. Web site]. 2013. Available at: http://www.reidsleeve.com/rsleeve.htm. Accessed May 14, 2018.

Preston NJ, Seers K, Mortimer PS. Physical therapies for reducing and controlling lymphoedema of the limbs (Review). The Cochrane Database of Systematic Reviews.2008;3. [The Cochrane Library Web site]. Available at: http://www.thecochranelibrary.com [via subscription only]. Accessed May 14, 2018.

Up to Date. Lymphedema: Prevention and treatment. 04/19/2013. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. Accessed May 14, 2018.

Up to Date. Medical management of lower extremity chronic venous disease. 04/30/2012. Available at: http://www.uptodate.com [via subscription only]. Accessed May 14, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

MEDICALLY NECESSARY


THE FOLLOWING CODES ARE USED TO REPRESENT ANTIEMBOLISM STOCKINGS:

A4490 Surgical stockings above knee length, each

A4495 Surgical stockings thigh length, each

A4500 Surgical stockings below knee length, each

A4510 Surgical stockings full-length, each


THE FOLLOWING CODES ARE USED TO REPRESENT COMPRESSION BURN GARMENTS:

A6501 Compression burn garment, bodysuit (head to foot), custom fabricated

A6502 Compression burn garment, chin strap, custom fabricated

A6503 Compression burn garment, facial hood, custom fabricated

A6504 Compression burn garment, glove to wrist, custom
fabricated

A6505 Compression burn garment, glove to elbow, custom fabricated

A6506 Compression burn garment, glove to axilla, custom fabricated

A6507 Compression burn garment, foot to knee length, custom fabricated

A6508 Compression burn garment, foot to thigh length, custom fabricated

A6509 Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated

A6510 Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated

A6511 Compression burn garment, lower trunk including leg openings (panty), custom fabricated

A6512 Compression burn garment, not otherwise classified

A6513 Compression burn mask, face and/or neck, plastic or equal, custom fabricated


THE FOLLOWING CODES ARE USED TO REPRESENT COMPRESSION STOCKINGS, NON-ELASTIC GRADIENT COMPRESSION WRAPS, AND NON-ELASTIC BINDERS:

A4465 Nonelastic binder for extremity

A6530 Gradient compression stocking, below knee, 18-30 mm Hg, each

A6531 Gradient compression stocking, below knee, 30-40 mm Hg, each

A6532 Gradient compression stocking, below knee, 40-50 mm Hg, each

A6533 Gradient compression stocking, thigh length, 18-30 mm Hg, each

A6534 Gradient compression stocking, thigh length, 30-40 mm Hg, each

A6535 Gradient compression stocking, thigh length, 40-50 mm Hg, each

A6536 Gradient compression stocking, full-length/chap style, 18-30 mm Hg, each

A6537 Gradient compression stocking, full-length/chap style, 30-40 mm Hg, each

A6538 Gradient compression stocking, full-length/chap style, 40-50 mm Hg, each

A6539 Gradient compression stocking, waist length, 18-30 mm Hg, each

A6540 Gradient compression stocking, waist length, 30-40 mm Hg, each

A6541 Gradient compression stocking, waist length, 40-50 mm Hg, each

A6544 Gradient compression stocking, garter belt

A6545 Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each

A6549 Gradient compression stocking/sleeve, not otherwise specified


THE FOLLOWING CODES ARE USED TO REPRESENT LYMPHEDEMA GARMENTS:

A4465 Nonelastic binder for extremity

L8010 Breast prosthesis, mastectomy sleeve

S8420 Gradient pressure aid (sleeve and glove combination), custom made

S8421 Gradient pressure aid (sleeve and glove combination), ready made

S8422 Gradient pressure aid (sleeve), custom made, medium weight

S8423 Gradient pressure aid (sleeve), custom made, heavy weight

S8424 Gradient pressure aid (sleeve), ready made

S8425 Gradient pressure aid (glove), custom made, medium weight

S8426 Gradient pressure aid (glove), custom made, heavy weight

S8427 Gradient pressure aid (glove), ready made

S8428 Gradient pressure aid (gauntlet), ready made

S8429 Gradient pressure exterior wrap


THE FOLLOWING CODE IS USED TO REPRESENT COMPRESSION GARMENTS FOR THE TREATMENT OF LYMPHEDEMA IN THE REGIONS OF TRUNK AND CHEST:

A9999 Miscellaneous DME supply or accessory, not otherwise specified



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 05.00.37f:
07/03/2018Effective 07/03/2018 this policy has been reviewed and reissued to communicate the Company’s continuing position on Compression Garments.
11/08/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Compression Garments.

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 05/06/2016
Version Issued Date: 05/06/2016
Version Reissued Date: 07/03/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.


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