0482 Compression Garments for the Legs (1) · Compression garments are usually made of elastic material, and are used to promote venous or lymphatic circulation. Compression garments

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Compression Garments for theLegs

Policy History

Last Review

08/09/2020

Effective: 08/24/2001

Next

Review: 05/27/2021

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0482

Policy *Please see amendment forPennsylvaniaMedicaid

at the end of this CPB.

Note: Aetna's standard benefit plans do not cover graded

compression stockings or non-elastic binders because they

are considered an outpatient consumable or disposable

supply. Please check benefit plan descriptions for details.

Inflatable compression garments*, non-elastic binders**, or

individually fitted prescription graded compression stockings*** are considered medically necessary for members who have

any of the following medical conditions:

I. Treatment of any of the following complications of

chronic venous insufficiency:

▪ Lipodermatosclerosis

▪ Stasis dermatitis (venous eczema)

▪ Varicose veins (except spider veins)

▪ Venous edema

▪ Venous ulcers (stasis ulcers) Proprietary

https://www.aetna.com/


II. Edema accompanying paraplegia, quadriplegia, etc.

III. Edema following surgery, fracture, burns, or other trauma

IV. Persons with lymphedema

(see CPB 0069 - Lymphedema (../1_99/0069.html))

V. Post sclerotherapy****

VI. Post-thrombotic syndrome (post-phlebitic syndrome)

VII. Postural hypotension

VIII. Prevention of thrombosis in immobilized persons (e.g.,

immobilization due to surgery, trauma, general debilitation,

etc.)

IX. Severe edema in pregnancy

These compression garments for the legs are considered

experimental and investigational for all other indications (e.g.,

improvement of functional performance in individuals with

Parkinson disease, improvement of knee proprioception in

rehabilitation setting, management of delayed-onset muscle

soreness, management of pain during post-natal care, and

management of spasticity following stroke).

* The above reference to inflatable compression garments

(e.g., Flowtron Compression Garment, Jobst Pneumatic

Compressor) also includes the pump needed to inflate the

compression garment. For Aetna's clinical policy on

intermittent and sequential compression pumps for

lymphedema,

see CPB 0069 - Lymphedema (../1_99/0069.html), and

CPB 0500 - Intermittent Pneumatic Compression Devices

(../500_599/0500.html)

.

**Aetna considers non-elastic leg binders (e.g., CircAid,

LegAssist, Reid Sleeve) medically necessary for members

who meet the selection criteria for pressure gradient support

stockings listed above. Non-elastic leg binders are similar to

graded compression stockings in that they provide static

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compression of the leg, but unlike graded compression

stockings, they do not use elastic, but use adjustable Velcro or

buckle straps.

***Applies only to pre-made or custom-made pressure gradient

support stockings (e.g., Jobst, Juzo, SigVarus, Venes, etc.)

that have a pressure of 18 mm Hg or more, that require a

physician's prescription, and that require measurements for

fitting.

****Only pressure gradient support stockings are considered

medically necessary for this indication; inflatable

compression garments have no proven value for this

indication.

Stockings purchased over the counter without a prescription

which have a pressure of less than 20 mm Hg (e.g., elastic

stockings, support hose, surgical leggings, anti-embolism

stockings (Ted hose) or pressure leotards) are considered

experimental and investigational because these supplies have

not been proven effective in preventing thromboembolism.

Note: These OTC stockings are also not covered because

they are not primarily medical in nature.

Silver impregnated compression stockings are considered not

medically necessary because there is insufficient evidence

that silver impregnated compression stockings are superior to

standard compression stockings.

Replacements

Replacements are considered medically necessary when the

compression garment can not be repaired or when required

due to a change in the member's physical condition. For

pressure gradient support stockings, no more

than 4 replacements per year are considered medically

necessary for wear.

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Two pairs of compression stockings are considered medically

necessary in the initial purchase (the 2nd pair is for use while

the 1st pair is in the laundry).

Contraindications

Compression garments are considered experimental and

investigational for members with severe peripheral arterial

disease or septic phlebitis because they are contraindicated in

these conditions.

Background

Compression garments are usually made of elastic material,

and are used to promote venous or lymphatic circulation.

Compression garments worn on the legs can help prevent

deep vein thrombosis and reduce edema, and are useful in a

variety of peripheral vascular conditions. Compression

garments can come in varying degrees of compression. The

higher degrees require a physician's prescription.

Fabric support garments are stockings or sleeves, usually

made of elastic that may be utilized for, but not limited to,

cases of severe edema, prevention of deep vein thrombosis

(DVT), venous insufficiency or for certain burn injuries to

lessen swelling and/or to reduce scarring. Alternatives to fabric

support garments include dietary changes, exercise, limb

elevation and weight control.

In an outcome-blinded, randomized controlled trial, Dennis et

al (2009) evaluated the effectiveness of thigh-length graduated

compression stockings (GCS) to reduce deep vein thrombosis

(DVT) following stroke. A total of 2,518 patients who were

admitted to hospital within 1 week of an acute stroke and who

were immobile were enrolled from 64 centers in the United

Kingdom, Italy, and Australia. Patients were allocated via a

central randomization system to routine care plus thigh-length

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GCS (n = 1,256) or to routine care plus avoidance of GCS (n =

1,262). A technician who was blinded to treatment allocation

undertook compression Doppler ultrasound of both legs at

about 7 to 10 days and, when practical, again at 25 to 30 days

after enrolment. The primary outcome was the occurrence of

symptomatic or asymptomatic DVT in the popliteal or femoral

veins. Analyses were by intention-to-treat. All patients were

included in the analyses. The primary outcome occurred in

126 (10.0 %) patients allocated to thigh-length GCS and in 133

(10.5 %) allocated to avoid GCS, resulting in a non-significant

absolute reduction in risk of 0.5 % (95 % confidence interval

[CI]: -1.9 % to 2.9 %). Blisters, ulcers, skin breaks, and skin

necrosis were significantly more common in patients allocated

to GCS than in those allocated to avoid their use (64 [5 %]

versus 16 [1 %]; odds ratio 4.18, 95 % CI: 2.40 to 7.27). The

authors concluded that these findings do not lend support to

the use of thigh-length GCS in patients admitted to hospital

with acute stroke. National guidelines for stroke might need to

be revised on the basis of these results.

The National Comprehensive Cancer Network's clinical

practice guideline on venous thromboembolic disease (2010)

states that GCS can be used in conjunction with a venous

compression device as a method of mechanical prophylaxis.

Ibuki and colleagues (2010) examined the effect of 3 tone-

reducing devices (dynamic foot orthosis, muscle stretch, and

orthokinetic compression garment) on soleus muscle reflex

excitability while standing in patients with spasticity following

stroke. A repeated measures intervention study was

conducted on 13 patients with stroke selected from a sample

of convenience. A custom-made dynamic foot orthosis, a

range of motion walker to stretch the soleus muscle and class

1 and class 2 orthokinetic compression garments were

assessed using the ratio of maximum Hoffmann reflex

amplitude to maximum M-response amplitude (Hmax:Mmax)

to determine their effect on soleus muscle reflex excitability.

Only 10 subjects were able to complete the testing. There

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were no significant treatment effects for the interventions (F =

1.208, df = 3.232, p = 0.328); however, when analyzed subject-

by-subject, 2 subjects responded to the dynamic foot orthosis

and 1 of those 2 subjects also responded to the class 1

orthokinetic compression garment. Overall, the results

demonstrated that the tone-reducing devices had no

significant effect on soleus reflex excitability suggesting that

these tone-reducing orthotic devices have no significant

neurophysiologic effect on spasticity.

Jaccard and colleagues (2007) noted that silver fiber-

containing compression stockings for the use in patients with

chronic venous insufficiency (CVI) were introduced to the

market. In order to gain some first insight into the effects of

these fabrics on the cutaneous microcirculation, a double-

blind, randomized cross-over trial was performed in 10 healthy

volunteers. A 3 days run-in phase preceded the (2 x 10 days)

treatment phases and was used to assess the reproducibility

of the primary endpoint, which was the transcutaneous partial

oxygen pressure (tcpO(2)) measured at a probe temperature

of 44 degrees C in the peri-malleolar region of the reference

leg in supine and dependent leg positions. Coefficients of

variation for double measured tcpO(2) values were 4.2 % (3.1

SD) and 5.8 % (6.0 SD) for the leg in supine and dependent

position. The intra-individual comparison of the effects from

both treatment phases (value end of treatment - start of

treatment) resulted in a negative tcpO(2) net balance for the

regular hosiery (-0.93 (2.7 SD) mm Hg, supine; -1.1 (3.5 SD)

mm Hg, dependent) but a positive net balance for the silver

fibers containing stockings (0.25 (4.0 SD) mm Hg, supine; 1.7

(3.9 SD) mm Hg, dependent). The inter-treatment differences

were statistically significant for the leg in a dependent

position. The trial provides first evidence that interweaving

silver threads into regular compression stockings may result in

a positive effect regarding the nutritive skin perfusion. This

was a small study done with healthy subjects; it is unclear

whether these findings can be extrapolated to patients who

require compression stockings.

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In a Cochrane review, O'Meara et al (2012) noted that the

main treatment for venous (or varicose or stasis) ulcers is the

application of a firm compression garment (bandage or

stocking) in order to aid venous return. There is a large

number of compression garments available and it was unclear

whether they are effective in treating venous ulcers and, if so,

which method of compression is the most effective. These

researchers performed a systematic review of all randomized

controlled trials (RCTs) evaluating the effects on venous ulcer

healing of compression bandages and stockings. Specific

questions addressed by the review are: does the application of

compression bandages or stockings aid venous ulcer healing?

and which compression bandage or stocking system is the

most effective? For this second update these investigators

searched: the Cochrane Wounds Group Specialised Register

(May 31, 2012); the Cochrane Central Register of Controlled

Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid

MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-

Process & Other Non-Indexed Citations May 30, 2012); Ovid

EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL

(1982 to May 30, 2012). No date or language restrictions were

applied. Randomized controlled trials recruiting people with

venous leg ulceration that evaluated any type of compression

bandage system or compression stockings were eligible for

inclusion. Eligible comparators included no compression (e.g.,

primary dressing alone, non-compressive bandage) or an

alternative type of compression. Randomized controlled trials

had to report an objective measure of ulcer healing in order to

be included (primary outcome for the review). Secondary

outcomes of the review included ulcer recurrence, costs,

quality of life, pain, adverse events and withdrawals. There

was no restriction on date, language or publication status of

RCTs. Details of eligible studies were extracted and

summarized using a data extraction table. Data extraction was

performed by 1 review author and verified independently by a

2nd review author. A total of 48 RCTs reporting 59

comparisons were included (4,321 participants in total). Most

RCTs were small, and most were at unclear or high-risk of

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bias. Duration of follow-up varied across RCTs. Risk ratio

(RR) and other estimates were shown below where RCTs

were pooled; otherwise findings refer to a single RCT. There

was evidence from 8 RCTs (unpooled) that healing outcomes

(including time to healing) are better when patients receive

compression compared with no compression. Single-

component compression bandage systems are less effective

than multi-component compression for complete healing at 6

months (1 large RCT). A 2-component system containing an

elastic bandage healed more ulcers at 1 year than one without

an elastic component (1 small RCT). Three-component

systems containing an elastic component healed more ulcers

than those without elastic at 3 to 4 months (2 RCTs pooled),

RR 1.83 (95 % CI: 1.26 to 2.67), but another RCT showed no

difference between groups at 6 months. An individual patient

data meta-analysis of 5 RCTs suggested significantly faster

healing with the 4-layer bandage (4LB) than the short stretch

bandage (SSB): median days to healing estimated at 90 and

99 respectively; hazard ratio 1.31 (95 % CI: 1.09 to 1.58).

High-compression stockings were associated with better

healing outcomes than SSB at 2 to 4 months: RR 1.62 (95 %

CI: 1.26 to 2.10), estimate from 4 pooled RCTs. One RCT

suggested better healing outcomes at 16 months with the

addition of a tubular device plus single elastic bandage to a

base system of gauze and crepe bandages when compared

with 2 added elastic bandages. Another RCT had 3 arms;

when 1 or 2 elastic bandages were added to a base

3-component system that included an outer tubular layer,

healing outcomes were better at 6 months for the 2 groups

receiving elastic bandages. There is currently no evidence of

a statistically significant difference for the following

comparisons: alternative single-component compression

bandages (2 RCTs, unpooled); 2-component bandages

compared with the 4LB at 3 months (3 RCTs pooled);

alternative versions of the 4LB for complete healing at times

up to and including 6 months (3 RCTs, unpooled); 4LB

compared with paste bandage for complete healing at 3

months (2 RCTs, pooled), 6 months or 1 year (1 RCT for each

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time point); adjustable compression boots compared with

paste bandages for the outcome of change in ulcer area at 3

months (1 small RCT); adjustable compression boots

compared with the 4LB with respect to complete healing at 3

months (1 small RCT); single-layer compression stocking

compared with paste bandages for outcome of complete

healing at 4 months (1 small RCT) and 18 months (another

small RCT); low compression stocking compared with SSB for

complete healing at 3 and 6 months (1 small

RCT);⋅compression stockings compared with a 2-component

bandage system and the 4LB for the outcome of complete

healing at 3 months (1 small, 3-armed RCT); and tubular

compression compared with SSB (1 small RCT) for complete

healing at 3 months. Secondary outcomes: 4LB was more cost-

effective than SSB. It was not possible to draw firm conclusions

regarding other secondary outcomes including recurrence,

adverse events and health-related quality of life. The authors

concluded that compression increases ulcer healing rates

compared with no compression. Multi- component systems are

more effective than single-component systems. Multi

component systems containing an elastic bandage appear to be

more effective than those composed mainly of inelastic

constituents. Two-component bandage systems appear to

perform as well as the 4LB. Patients receiving the 4LB heal

faster than those allocated the SSB. More patients heal on

high-compression stocking systems than with the SSB. They

stated that further data are required before the difference

between high-compression stockings and the 4LB can be

established.

Improvement of Functional Performance in Individuals with Parkinson Disease

Southard and colleagues (2016) noted that symptoms of

Parkinson's disease (PD) include bradykinesia, gait

abnormalities, balance deficits, restless leg syndrome, and

muscular fatigue. Compression garments (CG) have been

shown to improve performance in athletes by increasing

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venous return and reduce lactic acid. These researchers

evaluated the effect of CG on the performance of 3

standardized functional tests in persons with PD. The

functional tests selected represented strength, endurance, and

mobility measures in individuals with PD. A total of 19 males

and 2 females (aged 48 to 85 years) with PD participated in

this cross-over design study. Subjects were randomly

assigned to test under 2 conditions on 2 separate days: (i)

wearing below knee CG, and (ii) wearing sham stockings.

Outcome measures included 5 Times Sit to Stand (5XSTS),

gait speed, and 6 Minute Walk Test (6MWT). There were 7

days between trials. A paired t-test was used for each

dependent variable. Significance was set at p < 0.05. There

were no significant differences found between the CG and

sham socks for all outcome measures. Paired t-tests for the

dependent variables were gait speed (p = 0.729); 5XSTS (p =

0.880); 6MWT (p = 0.265); and rate of perceived exertion

(RPE) (p = 1.00). The authors concluded that data to support

the use of CG for enhanced proprioception, muscle power,

speed, and endurance is in need of further study with the PD

population. In particular, it is recommended that future studies

evaluate the possible physiological benefits of CG when worn

during exercise interventions.

Improvement of Knee Proprioception in Rehabilitation Setting

In a counter-balanced, single-blinded, cross-over study, Ghai

and associates (2018) examined the influence of below-knee

CG on proprioception accuracy under differential information

processing constraints designed to cause high or low

conscious attention to the task. A total of 44 healthy

participants (26 males/18 females) with a mean age of 22.7 ±

6.9 years performed an active joint re-positioning task using

their non-dominant and their dominant leg, with and without

below-knee CG and with and without conducting a secondary

task. Analysis of variance revealed no main effect of leg

dominance and no interactions (p's > 0.05). However, a main

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effect was evident for both compression (F1, 43 = 84.23, p <

0.001, ηp2 = 0.665) and secondary task (F1, 43 = 4.391, p =

0.04, ηp2 = 0.093). The authors concluded that this study was

the first to evaluate the effects of a below knee CG on knee

proprioception under differential information processing

constraints. They stated that proprioception accuracy of the

knee joint is significantly enhanced post application of below-

knee CG and when a secondary task is conducted

concurrently with active joint re-positioning. They noted that

these findings suggested that below-knee CG may improve

proprioception of the knee, regardless of leg dominance, and

that secondary tasks that direct attention away from

proprioceptive judgments may also improve proprioception,

regardless of the presence of compression. The authors

discussed clinical implications with respect to proprioception in

modern sports and rehabilitation settings.

Management of Delayed-Onset Muscle Soreness

Heiss and colleagues (2018a) noted that delayed-onset

muscle soreness (DOMS), an ultra-structural muscle injury, is

one of the most common reasons for impaired muscle

performance. These investigators examined the influence of

sport compression garments on the development of exercise-

induced intra-muscular (IM) edema in the context of DOMS.

DOMS was induced in 15 healthy subjects who performed a

standardized eccentric exercise of the calf muscles. Magnetic

resonance imaging (MRI) was performed at baseline and 60

hours after exercise (T2-weighted signal intensity and T2

relaxation time was evaluated in each compartment and the IM

edema in the medial head of the gastrocnemius muscle was

segmented). After the exercise, a conventional compression

garment (18 to 21 mmHg) was placed on 1 randomized calf for

60 hours. The level of muscle soreness was evaluated using

a visual analogue scale (VAS) for pain. T2-weighted signal

intensity, T2 relaxation time and IM edema showed a

significant interaction for time with increased signal

intensities/IM edema in the medial head of the gastrocnemius

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muscle at follow-up compared to baseline. No significant main

effect for compression or interaction between time and limb

occurred. Furthermore, no significant differences in the soleus

muscle and the lateral head of the gastrocnemius muscle were

observed between limbs or over time. After exercise, there

was significantly increased muscle soreness in both lower legs

in resting condition and when going downstairs and a

decreased range of motion (ROM) in the ankle joint. No

significant difference was observed between the compressed

and the non-compressed calf. The authors concluded that the

findings of this study showed that wearing conventional

compression garments after DOMS has been induced had no

significant effect on the development of muscle edema,

muscle soreness, ROM and calf circumference.

Heiss and colleagues (2018b) examined the influence of

compression garments on the development of DOMS, focusing

on changes in muscle perfusion and muscle stiffness. In this

controlled laboratory study with repeated measures, muscle

perfusion and stiffness, calf circumference, muscle soreness,

passive ankle dorsiflexion, and creatine kinase levels were

assessed in subjects before (baseline) a DOMS-inducing

eccentric calf exercise intervention and 60 hours later (follow

up). After DOMS induction, a sports compression garment (18

to 21 mmHg) was worn on 1 randomly selected calf until

follow-up, while the contralateral calf served as an internal

control. Muscle perfusion was assessed using contrast-

enhanced ultrasound (US; peak enhancement and wash-in

area under the curve), while muscle stiffness was assessed

using acoustic radiation force impulse (shear-wave velocities).

A MRI scan of both lower legs was also performed during the

follow-up testing session to characterize the extent of exercise-

induced muscle damage. Comparisons were made between

limbs and over time. Shear-wave velocity values of the medial

gastrocnemius showed a significant interaction between time

and treatment (p = 0.006), with the non-compressed muscle

demonstrating lower muscle stiffness values at follow-up

compared to baseline or to the compressed muscle. No

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significant differences in soleus muscle stiffness were noted

between limbs or over time, as was the case for muscle

perfusion metrics (peak enhancement and wash-in area under

the curve) for the medial gastrocnemius and soleus muscles.

Further, compression had no significant effect on passive

ankle dorsiflexion, muscle soreness, calf circumference, or

injury severity, per MRI scans. The authors concluded that

continuous wearing of compression garments during the

inflammation phase of DOMS may play an important role in

regulating muscle stiffness; however, compression garments

had no significant effects on IM perfusion or other common

clinical assessments.

Management of Pain During Post-Natal Care

Szkwara and colleagues (2019) stated that conservative

interventions for addressing pre-natal and post-natal ailments

have been described in the literature. Research findings

indicated that maternity support belts assist with reducing pain

and other symptoms in these phases; however, compliance in

wearing maternity support belts is poor. To combat poor

compliance, commercial manufacturers designed dynamic

elastomeric fabric orthoses (DEFO) / lycra-based compression

garments that target pre-natal and post-natal ailments. In a

systematic review, these investigators evaluated and

synthesized key findings on the feasibility, effectiveness, and

the acceptability of using DEFO to manage ailments during pre

natal and post-natal phases of care. They searched electronic

data-bases to identify relevant studies, resulting in 17 studies

that met the eligibility criteria. There were variations in DEFO

descriptors, including hosiery, support belts, abdominal binders

and more, making it difficult to compare findings from the

research articles regarding value of DEFO during pre-natal

and/or post-natal phases. A meta- synthesis of empirical

research findings suggested wearing DEFOs during pregnancy

has a significant desirable effect for managing pain and

improving functional capacity. Moreover, the authors concluded

that further research is needed to

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examine the use of DEFOs / compression garments for

managing pain in the post-natal period and improving quality

life (QOL) during pre-natal and post-natal care.

These researchers stated that although 17 studies were

included in this review, which examined a DEFO as an

intervention during pre-natal and post-natal phases, to-date,

there is still little high-quality evidence to support the use of

DEFO in pre-natal and post-natal populations. Small study

samples, inconsistent use of reliable and valid outcome

measures, and varied definitions of a DEFO and/or maternity

support belts have all contributed to the lack of high-quality

empirical studies on this topic. The meta-synthesis conducted

in the present review suggested that, during pregnancy,

wearing a DEFO can have a desirable positive effect for

managing pain and improving functional capacity. However,

there is limited evidence available to suggest that wearing a

DEFO during pregnancy can affect QOL. They stated that

more research is needed to determine the clinical relevance of

wearing a DEFO for women in the post-natal period. These

investigators noted that future research in this field should

include standardized outcome measures, standardized criteria

for DEFO, accurate product descriptions, and high-quality

study designs so that valid conclusions can be drawn and,

where applicable, research evidence can be implemented in

clinical practice.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

HCPCS codes covered if selection criteria are met:

A4465 Non-elastic binder for extremity

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A6507 Compression burn garment, foot to knee length,

custom fabricated

A6508 Compression burn garment, foot to thigh length,

custom fabricated

A6530 -

A6549

Gradient compression stocking

E0650 Pneumatic compressor, non-segmental home

model

E0651 Pneumatic compressor, segmental home model

without calibrated gradient pressure

E0652 Pneumatic compressor, segmental home model

with calibrated gradient pressure

E0660 Non-segmental pneumatic appliance for use

with pneumatic compressor, full leg

E0666 Non-segmental pneumatic appliance for use

with pneumatic compressor, half leg

E0667 Segmental pneumatic appliance for use with

pneumatic compressor, full leg

E0669 Segmental pneumatic appliance for use with

pneumatic compressor, half leg

E0671 Segmental gradient pressure pneumatic

appliance, full leg

E0673 Segmental gradient pressure pneumatic

appliance, half leg

HCPCS codes not covered for indications listed in the CPB:

E0675 Pneumatic compression device, high pressure,

rapid inflation/deflation cycle, for arterial

insufficiency (unilateral or bilateral system)

ICD-10 codes covered if selection criteria are met:

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G81.00 -

G81.94

Hemiplegia and hemiparesis

G82.20 -

G83.9

Paraplegia (paraparesis), quadriplegia

(quadriparesis) and other paralytic syndromes

I80.00 -

I80.209

I80.221 -

I80.3

Phlebitis and thrombophlebitis of superficial or

deep vessels of lower extremities

I83.001 -

I83.899

Varicose veins of lower extremities, with ulcer,

with inflammation, with ulcer and inflammation,

or with other complications

I87.00 -

I87.099

Postthrombotic syndrome

I87.2 Venous insufficiency (chronic)(peripheral)

I89.0 -

I89.9

Other noninfective disorders of lymphatic

vessels and lymph nodes

I95.1 Orthostatic hypotension

O12.00 -

O12.05

Gestational edema

O22.00 -

O22.03,

O87.4

Varicose veins of lower extremity in pregnancy

O90.89 Other complications of the puerperium, not

elsewhere classified [postpartum edema] [not

covered for pain during post-natal care]

Q82.0 Hereditary lymphedema

R60.0 -

R60.9

Edema, not elsewhere classified

Z74.01 Bed confinement status

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ICD-10 codes not covered for indications listed in the CPB:

G20 Parkinson's disease

I70.201 -

I70.299

Atherosclerosis of native arteries of the

extremities I70.301 -

I70.799

Atherosclerosis of bypass graft of the

extremities

I73.00 -

I73.9

I77.70 -

I77.79

Other peripheral vascular disease

I74.2 -

I74.4

Embolism and thrombosis of arteries of the

extremities

I77.1 Stricture of artery

I77.89 Other specified disorders of arteries and

arterioles

M79.18 Myalgia, other site [delayed-onset muscle

soreness]

The above policy is based on the following references:

1. Agnelli G, Sonaglia F. Prevention of venous

thromboembolism. Thromb Res. 2000;97(1):V49-V62.

2. Agu O, Hamilton G, Baker D. Graduated compression

stockings in the prevention of venous

thromboembolism. Br J Surg. 1999;86(8):992-1004.

3. Alguire PC, Mathes BM. Chronic venous insufficiency

and venous ulceration. J Gen Intern Med. 1997;12

(6):374-383.

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4. Amaragiri SV, Lees TA. Elastic compression stockings

for prevention of deep vein thrombosis. Cochrane

Database Syst Rev. 2000;(1):CD001484.

5. Amsler F, Blattler W. Compression therapy for

occupational leg symptoms and chronic venous

disorders: A meta-analysis of randomised controlled

trials. European J Vasc Endovasc Surg. 2008;35(3):366-

372.

6. Baker S, Fletcher A, Glanville J, et al. Compression

therapy for venous leg ulcers. Effective Health Care.

1997;3(1).

7. Bamigboye AA, Smyth R. Interventions for varicose

veins and leg oedema in pregnancy. Cochrane


8. Bergan JJ, Sparks SR. Non-elastic compression: An

alternative in management of chronic venous

insufficiency. J Wound Ostomy Continence Nurs.

2000;27(2):83-89.

9. Brandjes DP, Buller HR, Heijboer H, et al. Randomized

trial of effect of compression stockings in patients with

symptomatic proximal-vein thrombosis. Lancet.

1997;349(9054):759-762.

10. Buchtemann AS, Steins A, Yolkert B, et al. The effect of

compression therapy on venous haemodynamics in

pregnant women. Br J Obstet Gynaecol. 1999;106

(6):563-569.

11. Byrne B. Deep vein thrombosis prophylaxis: The

effectiveness and implications of using below-knee or

thigh-length graduated compression stockings. Heart

Lung. 2001;30(4):277-284.

12. CIGNA HealthCare Medicare Administration. Coverage

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0482 Compression

Garments for the Legs

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 08/09/2020

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http://www.aetnabetterhealth.com/pennsylvania

Documents

0482 Compression Garments for the Legs (1) · Compression garments are usually made of elastic material, and are used to promote venous or lymphatic circulation. Compression garments