Pneumatic Compression Devices - Oxford Health Plans

CLINICAL POLICY

PNEUMATIC COMPRESSION DEVICES

Policy Number: DME 037.5 T2
Effective Date: April 1, 2016

Table of Contents Page Related Policy:
DME, Orthotics, Ostomy
CONDITIONS OF COVERAGE………………………... 1 Supplies, Medical
BENEFIT CONSIDERATIONS…................................ 1 Supplies, and
COVERAGE RATIONALE........................................... 2 Repairs/Replacements
2
APPLICABLE CODES................................................. 2
3
U.S. FOOD AND DRUG ADMINISTRATION...............

POLICY HISTORY/REVISION INFORMATION...........

The services described in Oxford policies are subject to the terms, conditions and limitations of the
Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare
Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as
necessary without prior written notice unless otherwise required by Oxford's administrative
procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of
its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products.

Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage

is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If
there is a difference between any policy and the Member’s plan of benefits or Certificate of

Coverage, the plan of benefits or Certificate of Coverage will govern.

CONDITIONS OF COVERAGE

Applicable Lines of Business/Products This policy applies to Oxford Commercial plan
membership.
Benefit Type DME
Referral Required No

(Does not apply to non-gatekeeper products) Yes

Authorization Required Yes1

(Precertification always required for inpatient admission) All

Precertification with Medical Director 1Review by a Medical Director and/ or their
Review Required designee is required
Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is
required)

Special Considerations

BENEFIT CONSIDERATIONS

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA)

requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large

Pneumatic Compression Devices: Clinical Policy (Effective 04/01/2016) 1
©1996-2016, Oxford Health Plans, LLC

group plans (both self-funded and fully insured), and small group ASO plans, are not subject to
the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage
for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar
limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The
determination of which benefits constitute EHBs is made on a state by state basis. As such,
when using this guideline, it is important to refer to the member specific benefit document to
determine benefit coverage.

COVERAGE RATIONALE

For information regarding medical necessity review of pneumatic compression devices, see
MCG™ Care Guidelines, 20th edition, 2016, Intermittent Pneumatic Compression with Extremity

Pump ACG: ACG: A-0340 (AC).

APPLICABLE CODES

The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service
code in this policy does not imply that the service described by this code is a covered or non-
covered health service. Coverage is determined by the enrollee specific benefit document and
applicable laws that may require coverage for a specific service. The inclusion of a code does not
imply any right to reimbursement or guarantee claims payment. Other policies and coverage
determination guidelines may apply. This list of codes may not be all inclusive.

HCPCS Code Description
A4600 Sleeve for intermittent limb compression device, replacement only
E0650 Pneumatic compressor, nonsegmental home model
E0651 Pneumatic compressor, segmental home model without calibrated gradient
pressure
E0655 Nonsegmental pneumatic appliance for use with pneumatic compressor, half
arm
E0660 Nonsegmental pneumatic appliance for use with pneumatic compressor, full
leg
E0665 Nonsegmental pneumatic appliance for use with pneumatic compressor, full
arm
E0666 Nonsegmental pneumatic appliance for use with pneumatic compressor, half
E0667 leg
E0668 Segmental pneumatic appliance for use with pneumatic compressor, full leg
E0669 Segmental pneumatic appliance for use with pneumatic compressor, full arm
E0670 Segmental pneumatic appliance for use with pneumatic compressor, half leg
E0671 Segmental pneumatic appliance for use with pneumatic compressor,
E0672 integrated, 2 full legs and trunk
E0673 Segmental gradient pressure pneumatic appliance, full leg
E0675 Segmental gradient pressure pneumatic appliance, full arm
Segmental gradient pressure pneumatic appliance, half leg
E0676 Pneumatic compression device, high pressure, rapid inflation/deflation cycle,
for arterial insufficiency (unilateral or bilateral system)
Intermittent limb compression device (includes all accessories), not
otherwise specified

U.S. FOOD AND DRUG ADMINISTRATION (FDA)

Devices and systems to perform pneumatic compression are regulated by the FDA as Class II
devices. See the following Web site for more information (use product code JOW):
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed December 2016.

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POLICY HISTORY/REVISION INFORMATION

Date Action/Description
04/01/2016
 Revised coverage rationale:
o Replaced reference to “MCG™ Care Guidelines, 19th edition, 2015”
with “MCG™ Care Guidelines, 20th edition, 2016” (effective Apr. 1,

2016); refer to 20th edition for complete details on applicable
updates to the MCG™ Care Guidelines

 Archived previous policy version DME 037.4 T2

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©1996-2016, Oxford Health Plans, LLC