Medicare Advantage

Medical Policy

Title:

Compression Garments

Policy #:

MA05.045b

Policy

MEDICALLY NECESSARY

COMPRESSION BURN GARMENTS
Compression burn garments are considered medically necessary and, therefore, covered when a compression burn garment is prescribed following a burn injury.

GRADIENT COMPRESSION STOCKINGS AND NON-ELASTIC COMPRESSION GARMENTS FOR THE LOWER EXTREMITIES
Below-the-knee gradient compression stockings (eg, Jobst stockings) with pressure between 30 mmHg and 50 mmHg are considered medically necessary and, therefore, covered when the stocking is used to secure a primary dressing over a debrided venous stasis ulcer.

GRADIENT COMPRESSION WRAPS
One below-the-knee gradient compression wrap per leg is considered medically necessary and, therefore, covered every six months when used in the treatment of an open venous stasis ulcer. Additional wraps are considered not medically necessary and, therefore, not covered.

NOT COVERED

GARMENTS FOR UPPER EXTREMITY LYMPHEDEMA (GRADIENT PRESSURE AIDS, NON-ELASTIC COMPRESSION GARMENTS, AND MASTECTOMY SLEEVES)
Lymphedema garments such as gradient pressure aids (eg, a glove or gauntlet), mastectomy sleeves, and non-elastic compression garments (eg, ReidSleeve®, CircAid®, ArmAssist®) are not covered by Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

COMPRESSION GARMENTS FOR THE TRUNK OR CHEST
Compression garments for the trunk or chest (eg, JoVi Vest®) are not covered by Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic-deterrent [TED]) stockings are not covered by Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement

GRADIENT COMPRESSION STOCKINGS AND NON-ELASTIC COMPRESSION GARMENTS FOR THE LOWER EXTREMITIES
All other gradient compression stockings and non-elastic compression garments for the lower extremities (eg, CircAid®, LegAssist®, Reid Sleeve®) are not covered by Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement.

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 original standard written 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 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

This policy is consistent with Medicare's coverage criteria. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, compression garments are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified as noncovered are not eligible for coverage reimbursement by the Company.

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 (eg, glove-to-axilla, foot-to-knee, or upper/lower trunk), and stockings are available in varying pressures and lengths (eg, waist length, thigh length, full length, and below-the-knee).

TYPES OF COMPRESSION GARMENTS

BURN GARMENTS
Compression burn garments (eg, 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 (eg, 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 (eg, 20-30 mmHg, 30-40 mmHg).

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.

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).

References

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 April 15, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A52478 External Breast Prostheses. [Noridian Health Care Solutions]. Original: 10/01/2015. (Revised 01/01/2020). Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52478&ver=20&DocID=A52478&bc=gAAAAAgAAAAA&. Accessed April 15, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A54563 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised 05/01/2021). Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54563&ver=24&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Surgical+Dressings&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed April 15, 2022.

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://med.noridianmedicare.com/documents/2230703/7218263/External+Breast+Prostheses+LCD+and+PA. Accessed April 15, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33831 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 05/01/2021). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=30&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Surgical+Dressings&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed April 15, 2022.

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

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

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

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

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

NOT COVERED

A4465 Nonelastic binder for extremity

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

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, 40-50 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

A6549 Gradient compression stocking/sleeve, not otherwise specified

E0677 Non-pneumatic sequential compression garment, trunk

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 TRUNKS AND CHEST:

A9999 Miscellaneous DME supply or accessory, not otherwise specified

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

A1 - Dressing for one wound

A2 - Dressing for two wounds

A3 - Dressing for three wounds

A4 - Dressing for four wounds

A5 - Dressing for five wounds

A6 - Dressing for six wound

A7 - Dressing for seven wounds

A8 - Dressing for eight wounds

A9 - Dressing for nine wounds

AW - Item furnished in conjunction with a surgical dressing

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

4/1/2023

Version Issued Date:

4/6/2023

Version Reissued Date: