![]() Treatment of upper extremity lymphedema following surgery.Treatment of sensory impairment in the upper limb following stroke.Treatment of peripheral arterial occlusive disease/arterial insufficiency.Treatment of lower limb lymphedema in persons with type 2 diabetes mellitus.Rehabilitation for distal radial fractures.Prophylaxis of venous thromboembolism in neurosurgical procedures that do not prevent ambulation.Management of edema following femoro-popliteal bypass surgery.Enhancement of fracture and soft-tissue healing.Enhancement of Achilles tendon rupture healing.Note: the presence of a cast or splint, the use of an assistive device (e.g., walker, crutches), or non-weightbearing status alone due to injury or surgery are not considered "bedridden" for the purpose of this policy.Īetna considers intermittent pneumatic compression (IPC) devices experimental and investigational for the following (not an all-inclusive list) because there is inadequate evidence of their effectiveness for these indications: A segmented device with manual control of the pressure in each chamber is considered medically necessary only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented device without manual control of the pressure in each chamber.Īetna considers intermittent pneumatic compression devices of the lower extremities medically necessary DME to stimulate circulation and reduce the chances of deep venous thromboses for members who are bedridden due to trauma, orthopedic surgery, neurosurgery or other circumstances preventing ambulation. A segmented device with manual control of the pressure in each chamber is considered medically necessary only if there is clear documentation of medical necessity in the individual case. When a pneumatic compression device is determined to be medically necessary, a non-segmented device or segmented device without manual control of the pressure in each chamber is generally considered adequate to meet the clinical needs of the member. 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. Number: 0500 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background ReferencesĪetna considers full-leg or half-leg pneumatic compression devices for home use medically necessary durable medical equipment (DME) for the treatment of chronic venous insufficiency of the legs of members who have venous stasis ulcers that have failed to heal after a 6-month trial of conservative therapy directed by the treating physician.
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