Commercial

Medical Policy

Title:

Compression Garments

Policy #:

05.00.37i

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.

MEDICALLY NECESSARY

BURN GARMENTS
A compression burn garment 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.

DAYTIME COMPRESSION GARMENTS

Daytime compression garments (e.g., stockings, wraps, sleeves, toe caps, vests) are considered medically necessary and, therefore, covered when prescribed as part of a complete decongestive therapy (CDT) program for lymphedema for a maximum number of six garments per each affected area in a 12-month period.

GRADIENT COMPRESSION SURGICAL DRESSING WRAPS/STOCKINGS

Gradient compression surgical dressing nonelastic wraps with a pressure between 30 and 50 mm Hg are considered medically necessary and, therefore, covered when prescribed for open venous stasis ulcers and/or surgically created wounds for a maximum number of two garments per each leg in a 12-month period.

Gradient compression surgical dressing stockings with a pressure between 30 and 50 mm Hg are considered medically necessary and, therefore, covered when prescribed for open venous stasis ulcers and/or surgically created wounds.

NIGHTTIME COMPRESSION GARMENTS

Nighttime compression garments (e.g., gloves, bras, garments for upper and lower extremities) are considered medically necessary and, therefore, covered when prescribed as part of a complete decongestive therapy (CDT) program for lymphedema for a maximum number of one garment per each affected area in a 12-month period.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic deterrent [TED]) stockings 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.

ACCESSORIES AND BANDAGING ROLLS/SUPPLIES

Accessories and bandaging supplies (e.g., aids for donning and doffing garments for different body parts, fillers, lining, padding, zippers) for the appropriate use of a compression garment are considered medically necessary and, therefore, covered when prescribed for lymphedema compression garments.

NOT MEDICALLY NECESSARY

Compression garments that exceed the established frequency limits 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:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an standard written original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The 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 7 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 5 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 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). They typically fall within four different categories: Circular knit (i.e., “ready to wear”), flat knit (i.e., “made-to-measure”), inelastic adjustable wraps, and nighttime garments. They typically fall within four different categories: Circular knit (i.e., “ready to wear”), flat knit (i.e., “made-to-measure”), inelastic adjustable wraps, and nighttime garments. Made-to-measure, or custom fitted, gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression treatment for lymphedema or burn injuries. Some examples for which a custom fitted garment may be appropriate (not all-inclusive) include:

If the circumference of the proximal portion of the limb is significantly greater than the distal limb
If the skin/tissue has folds or contours requiring a specific type of knitting pattern
Beneficiary is unable to tolerate the fabric composition of the standard garment

A nonoperative standard of care for peripheral lymphedema is an individualized approach comprising complete decongestive therapy (CDT). CDT generally includes manual lymphatic drainage, multilayer short-stretch compression bandaging, daytime and nighttime compression garments, exercise, and the adjunctive use of pneumatic compression. Various professional societies including the International Society of Lymphology, American Venous Forum, American Vein and Lymphatic Society, and the Society for Vascular Medicine support the use of compression garments as part of a CDT program based on expert consensus and evidence-based practice.

TYPES OF COMPRESSION GARMENTS

BURN GARMENTS

Compression burn garments (e.g., stockings, 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, VENOUS STASIS ULCER, AND SURGICALLY CREATED WOUND GARMENTS
Gradient Compression Garments and Dressings for the Lower Extremities

Daytime gradient compression garments for the lower extremities (e.g., stockings, full-length chaps) are used to control the excessive accumulation of lymphatic fluid in the legs of individuals with lymphedema. These garments 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 garments for the lower extremities are available in a variety of pressure levels (e.g., 18–30 mm Hg, 30–40 mm Hg, 40–50 mm Hg).

Gradient compression wraps work in a similar manner as, and can be an alternative to, gradient compression stockings. These garments are nonelastic and can be used for the treatment of lymphedema. Wraps can also be used as a surgical dressing in the treatment of open venous stasis ulcers and surgically created wounds. 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.

Gradient Compression Garments for Upper Extremities

Similarly to lower extremity garments, daytime gradient compression garment (e.g., gloves, gauntlets, sleeves) for upper extremities are used to control the excessive accumulation of lymphatic fluid using various pressure levels ranging from 20 to 40 mm Hg. The length of a knitted sleeve gradually increases from the wrist to the upper portion of the sleeve.

Gradient Compression and Non-Elastic Garments for the Torso
Additional daytime compression garments that are commercially available include those for the treatment of lymphedema of the torso (e.g., breast garments). 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 CDT program.

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).

Alternate Gradient Compression Garments

The excessive accumulation of lymphatic fluid can occur throughout the body due to a blockage or damage to the lymph system. While swelling most commonly occurs in the arm or leg, a variety of garments exist for the treatment of lymphedema in other body areas such as but not limited to the neck, head, genital, and foot regions.

Nighttime Compression Garments

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 isnighttime garments. Nighttime compression garments are non-elastic and provide gentle gradient pressure to the limb through a garment with a foam liner and a series of adjustable straps. Because of their inelastic components, nighttime garments do not break down with wear as quickly as traditional daytime garments.

Accessories and Bandaging Rolls/Supplies

A wide range and variety of accessories and bandaging supplies are readily available for the effective use of garments and wraps, including but not limited to zippers, linings, padding, and fillers that may be necessary for the effective use of a lymphedema compression treatment item. They may be part of the garment as furnished or worn underneath a compression garment or wrap.

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.

References

Agency for Healthcare Research and Quality (AHRQ). Technology Assessment: Diagnosis and Treatment of Secondary Lymphedema. [Centers for Medicare & Medicaid Services Web site]. 05/28/2010. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id66aTA.pdf. Accessed August 31, 2023.

American Cancer Society (ACS). Women's Health and Cancer Rights Act. [ACS Web site]. 05/13/2019. 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 August 31, 2023.

Armstrong DG, Meyr AJ. Compression therapy for the treatment of chronic venous insufficiency. [UpToDate Web site]. 08/18/2023. Available at https://www.uptodate.com/contents/compression-therapy-for-the-treatment-of-chronic-venous-insufficiency?search=management of lower extremity chronic venous disease&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H442681185 [via subscription only]. Accessed August 31, 2023.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 01/01/2020. Available at:https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis. Accessed August 31, 2023.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Calendar Year (CY) 2024 Home health (HH) prospective payment system rate update; HH quality reporting program requirements; HH value-based purchasing expanded model requirements; home intravenous immune globulin items and services; Hospice informal dispute resolution and special focus program requirements, certain requirements for durable medical equipment prosthetics and orthotics supplies; and provider and supplier enrollment requirements. Final Rule CMS-1780-F. [Federal Register Web site]. 01/01/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2023-11-13/pdf/2023-24455.pdf. Accessed December 20, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Porcine Skin and Gradient Pressure Dressings (270.5). [CMS website]. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAgAAAAAAA&. Accessed August 31, 2023.

Company Benefit Contracts.

European Wound Management Association (EWMA). Lymphoedema bandaging in practice. Medical Education Partnership. [EWMA Web site]. 2005. Available at: https://ewma.org/fileadmin/user_upload/EWMA.org/Position_documents_2002-2008/English_focus_doc_05.pdf. Accessed August 31, 2023.

Fukaya E, O'Banion LA, Kiguchi M, Judelson DR. Evaluation and management of chronic venous insufficiency including venous leg ulcer. [UpToDate Web site]. 07/13/2023. Available at https://www.uptodate.com/contents/evaluation-and-management-of-chronic-venous-insufficiency-including-venous-leg-ulcer?search=Medical management of lower extremity chronic venous disease&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1234281149 [via subscription only]. Accessed August 31, 2023.

Hettrick H, Ehmann S, McKeown B, et al. Selecting appropriate compression for lymphedema patients: American Vein and Lymphatic Society position statement. Phlebology. 2023;38(2):115-118.

Howell D, Ezzo J, Bily L, Johansson K. Complete decongestive therapy for lymphedema following breast cancer treatment (Protocol). Cochrane Database Syst Rev. 2002;1. Art. No.:CD003475.

International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the International Society of Lymphology. [Lymphology Web site]. 2020. Available at: https://journals.librarypublishing.arizona.edu/lymph/article/id/4649/. Accessed August 31, 2023.

Lurie F, Malgor RD, Carman T, et al. The American Venous Forum, American Vein and Lymphatic Society, and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology. 2022;37(4):252-266.

Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. London: MEP Ltd, 2006. Available at: https://www.lympho.org/wp-content/uploads/2021/09/Best_practice.pdf. Accessed August 31, 2023.

McNeely ML, Dolgoy ND, Rafn BS, et al. Nighttime compression supports improved self-management of breast cancer-related lymphedema: A multicenter randomized controlled trial. Cancer. 2022;128(3):587-596.

Mehrara B. Clinical staging and conservative management of peripheral lymphedema. [UpToDate Website]. 04/04/2022. Available at: https://www.uptodate.com/contents/clinical-staging-and-conservative-management-of-peripheral-lymphedema?search=treatment of lymphadema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 [via subscription only]. Accessed August 31, 2023.

National Lymphedema Network (NLN). Position statement of the National Lymphedema Network. Diagnosis and treatment of lymphedema. [NLN Web site]. May 2012. Available at: https://lymphnet.org/position-papers. Accessed May 27, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A52478 External Breast Prostheses. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 01/01/20). Available at:
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52478&ver=22&DocID=A52478&bc=gAAAAAgAAAAA&=. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A54563 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised 01/01/20). Available at:
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=54563&ver=41. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33317 External Breast Prostheses. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 01/01/20). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33317. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33831 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 01/01/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831&ver=40&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Surgical+Dressings&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&=. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Medical Director Articles. Lymphedema Compression Treatment Items - Correct Coding and Billing. Original: 12/8/2023. Available at: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/2023/lymphedema-compression-treatment-items-correct-coding-and-billing. Accessed December 20, 2023.

O'Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers (review). Cochrane Database Syst Rev. 2012;1. [National Library of Medicine Web site]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068175/pdf/CD000265.pdf. Accessed August 31, 2023.

Rabe E, Partsch H, Hafner J, et al. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology. 2018;33(3):163-184.

Peninsula Medical, Inc. The Reid sleeve classic. [Peninsula Medical, Inc. Web site]. Available at: http://www.reidsleeve.com/rsleeve.htm. Accessed August 31, 2023.

Shi C, Dumville JC, Cullum N, et al. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database Sys Rev. 2021;7. Art. No.:CD013397.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

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 LYMPHEDEMA GARMENTS:

A4465 Nonelastic binder for extremity

A6520 Gradient compression garment, glove, padded, for nighttime use, each

A6521 Gradient compression garment, glove, padded, for nighttime use, custom, each

A6522 Gradient compression garment, arm, padded, for nighttime use, each

A6523 Gradient compression garment, arm, padded, for nighttime use, custom, each

A6524 Gradient compression garment, lower leg and foot, padded, for nighttime use, each

A6525 Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each

A6526 Gradient compression garment, full leg and foot, padded, for nighttime use, each

A6527 Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each

A6528 Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6529 Gradient compression garment, bra, for nighttime use, custom, each

A6530 Gradient compression stocking, below knee, 18-30 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 mmHg, or greater, 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 mmHg, or greater 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 mmHg or greater, each

A6544 Gradient compression stocking, garter belt

A6549 Gradient compression garment not otherwise specified

A6552 Gradient compression stocking, below knee, 30-40 mmhg, each

A6553 Gradient compression stocking, below knee, 30-40 mmhg, custom, each

A6554 Gradient compression stocking, below knee, 40 mmhg or greater, each

A6555 Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

A6556 Gradient compression stocking, thigh length, 18-30 mmhg, custom, each

A6557 Gradient compression stocking, thigh length, 30-40 mmhg, custom, each

A6558 Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

A6559 Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each

A6560 Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each

A6561 Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each

A6562 Gradient compression stocking, waist length, 18-30 mmhg, custom, each

A6563 Gradient compression stocking, waist length, 30-40 mmhg, custom, each

A6564 Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

A6565 Gradient compression gauntlet, custom, each

A6566 Gradient compression garment, neck/head, each

A6567 Gradient compression garment, neck/head, custom, each

A6568 Gradient compression garment, torso and shoulder, each

A6569 Gradient compression garment, torso/shoulder, custom, each

A6570 Gradient compression garment, genital region, each

A6571 Gradient compression garment, genital region, custom, each

A6572 Gradient compression garment, toe caps, each

A6573 Gradient compression garment, toe caps, custom, each

A6574 Gradient compression arm sleeve and glove combination, custom, each

A6575 Gradient compression arm sleeve and glove combination, each

A6576 Gradient compression arm sleeve, custom, medium weight, each

A6577 Gradient compression arm sleeve, custom, heavy weight, each

A6578 Gradient compression arm sleeve, each

A6579 Gradient compression glove, custom, medium weight, each

A6580 Gradient compression glove, custom, heavy weight, each

A6581 Gradient compression glove, each

A6582 Gradient compression gauntlet, each

A6583 Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each

A6584 Gradient compression wrap with adjustable straps, not otherwise specified

A6585 Gradient pressure wrap with adjustable straps, above knee, each

A6586 Gradient pressure wrap with adjustable straps, full leg, each

A6587 Gradient pressure wrap with adjustable straps, foot, each

A6588 Gradient pressure wrap with adjustable straps, arm, each

A6589 Gradient pressure wrap with adjustable straps, bra, each

A6593 Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6594 Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each

A6595 Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each

A6596 Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each

A6597 Gradient compression bandage roll, elastic long stretch, linear yard, any width, each

A6598 Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each

A6599 Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each

A6600 Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each

A6601 Gradient compression bandaging supply, high density foam pad, any size or shape, each

A6602 Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each

A6603 Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each

A6604 Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each

A6605 Gradient compression bandaging supply, padded foam, per linear yard, any width, each

A6606 Gradient compression bandaging supply, padded textile, per linear yard, any width, each

A6607 Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each

A6608 Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each

A6609 Gradient compression bandaging supply, not otherwise specified

A6610 Gradient compression stocking, below knee, 18-30 mmhg, custom, each

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

SURGICAL DRESSINGS

A6531 Gradient compression stocking, below knee, 30-40 mm Hg, used as a surgical dressing, each

A6532 Gradient compression stocking, below knee, 40-50 mm Hg, used as a surgical dressing, each

SURGICAL DRESSING WRAP

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

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 05.00.37i:

01/01/2024

The version of the policy will be issued on 02/05/2024 with a retroactive effective date of 01/01/2024.

The following policy criteria have been added to this policy:

Various daytime and nighttime compression garments, as well as accessories and bandaging rolls/supplies for the prevention and/or treatment of lymphedema were added as medically necessary.
Frequency limits for daytime and nighttime gradient compression garments.

The following HCPCS codes have been added to this policy as medically necessary:

A6566, A6567, A6570, A6571, A6572, A6573, A6594, A6595, A6596, A6597, A6604, A6605, A6606, A6607, A6608, A6609

The following HCPCS code has been removed from this policy:

E0677 Non-pneumatic sequential compression garment, trunk

Revisions From 05.00.37h:

01/02/2024

This policy has been identified for the HCPCS code update effective 01/02/2024.

The following HCPCS codes have been added to the policy:

A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6528, A6529, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6559, A6560, A6561, A6562, A6563, A6564, A6565, A6568, A6569, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6589, A6593, A6610

The following HCPCS narratives have been revised in the policy:

A6531:

FROM Gradient compression stocking, below knee, 30-40 mmHg, each
TO Gradient compression stocking, below knee, 30-40 mmHg, used as a surgical dressing, each

A6532:

FROM Gradient compression stocking, below knee, 40-50 mmHg, each

TO Gradient compression stocking, below knee, 40-50 mmHg, used as a surgical dressing, each

A6535:

FROM Gradient compression stocking, thigh length, 40-50 mmHg, each

TO Gradient compression stocking, thigh length, 40 mmHg, or greater, each

A6538:

FROM Gradient compression stocking, full-length/chap style, 40-50 mmHg, each

TO Gradient compression stocking, full length/chap style, 40 mmHg, or greater, each

A6541:

FROM Gradient compression stocking, waist length, 40-50 mmHg, each

TO Gradient compression stocking, waist length, 40 mmHg, or greater, each

A6545:

FROM Gradient compression wrap, nonelastic, below knee, 30-50 mmHg, each

TO Gradient compression wrap, non-elastic, below knee, 30-50 mmHg, used as a surgical dressing

A6549:

FROM Gradient compression stocking/sleeve, not otherwise specified

TO Gradient compression garment not otherwise specified

Revisions From 05.00.37g:

10/04/2023

The policy has been reissued in accordance with the Company's annual review process.

04/01/2023

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified and updated for the CPT code update effective 04/01/2023.

The following HCPCs code has been added to the policy:

E0677 Non-pneumatic sequential compression garment, trunk

Revisions From 05.00.37f:

06/29/2022

The policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.

05/19/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.
07/01/2020	The policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.
08/14/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.
07/03/2018	Effective 07/03/2018 this policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.
11/08/2017	The 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:

1/1/2024

Version Issued Date:

2/5/2024

Version Reissued Date: