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LCD - Lymphedema Pump

Coverage Summary

Written Order Prior to Delivery Required:

For General Lymphadema, a four-week trial of conservative therapy must be completed and documented. The four-week trial includes (1-3):

  1. Appropriate compression bandage system or compression garment, and
  2. Exercise
  3. Elevation of the limb

Order Requirements

  1. Patient's Name
  2. Detailed description of item being ordered
  3. Quantity to be dispensed
  4. Prescribed pump settings
  5. Prescribed frequency of use (hours per day, days per week)
  6. Length of Medical Need
  7. Ordering Physician’s NPI
  8. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  9. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  10. Start date of the order – if different than physician signature date.

Coverage Detail

A Pneumatic Compression Devices (E0652) is only covered for Lymphdema or Chronic Venous Insufficiency with Venous Stasis Ulcers.

Lyphedema: patinet has to undergone a four-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.

  • Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as radical surgical procedures with removal of regional groups of lymph nodes for example, after radical mastectomy, post-radiation fibrosis, and spread of malignant tumors to regional lymph nodes with lymphatic obstruction, among other causes)

Chronic Venous Insufficiency: with Venous Stasis Ulcers of the lower extremities only if the beneficiary has one or more venous stasis ulcer(s) which have failed to heal after a six month trial of conservative therapy directed by the treating physician. The trial of conservative therapy must include a compression bandage system or compression garment, appropriate dressings for the wound, exercise, and elevation of the limb.

Chronic venous insufficiency of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.)