![]() Only when no significant improvement has occurred in the most recent 4 weeks and the medical necessity criteria above are still met, may the lymphedema be considered unresponsive to conservative therapy, and a pneumatic compression device without calibrated gradient pressure would be considered medically necessary.Īt a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate. Where improvement has occurred, the trial of conservative therapy must be continued with subsequent reassessment at intervals at least 1 week apart. When available, manual lymphatic drainage is a key component of conservative treatment as is appropriate medication treatment when there is concurrent congestive failure.Īt the end of the 4-week trial, if there has been improvement, then a pneumatic compression device is considered not medically necessary. Regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression:.The compression used must not create a tourniquet effect at any point. Adequate compression is defined as sufficient pressure at the lowest pressure point to cause fluid movement and (sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal to proximal.Regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression: In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial of conservative therapy that must include all of the following: Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology and.Skin breakdown with persisting lymphorrhea, or.Marked hyperkeratosis with hyperplasia and hyperpigmentation.The member has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings:.The member has a diagnosis of lymphedema and.Pneumatic Compression Device Without Calibrated Gradient PressureĪetna considers home use of a non-segmented (unicompartmental) device or segmented (multicompartmental) pneumatic compression device without manual control of the pressure in each chamber medically necessary for members with chronic and severe lymphedema when all of the following requirements are met:.The member has shown a past record of compliance and the member or his/her caregiver is capable of following the instructions associated with CDP.Īetna considers lymphedema pumps (pneumatic compression devices) medically necessary durable medical equipment (DME) for home use according to the following criteria: One or more previous admissions to treat complications of intractable lymphedema (i.e., cellulitis, ulceration) and.Intractable lymphedema of the extremities, unrelieved by elevation or.Evidence of ulceration due to lymphedema or.The member has any of the following conditions: This Clinical Policy Bulletin addresses lymphedema.Īetna considers a course of complex decongestive physiotherapy (CDP), also called complete decongestive therapy, or manual lymphoid drainage, medically necessary when both of the following criteria are met: Number: 0069 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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