Prior Authorization Review Panel MCO Policy Submission A ...€¦ · The above reference to inflatable compression garments (e.g., Flowtron Compression Garment, Jobst Pneumatic Compressor)

Prior Authorization Review PanelMCO Policy Submission

A separate copy of this form must accompany each policy submitted for review.Policies submitted without this form will not be considered for review.

Plan: Aetna Better H ealth Submission Date:08/01/2019

Policy Number: 0482 Effective Date: Revision Date: 07/09/2019

Policy Name: Compression Garments for the Legs

Type of Submission – Check all that apply:

New Policy Revised Policy* Annual Review – No Revisions Statewide PDL

*All revisions to the policy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0482 Compression Garments for the Legs

This CPB has been revised to state that compression garments for the legs are considered experimental and investigational for management of delayed-onset muscle soreness.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

Revised July 22, 2019

http://www.aetna.com/cpb/medical/data/400_499/0482.html 07/29/2019

Page 1 of 17

(https://www.aetna.com/)

Compression Garments for theLegs

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Policy History

Last Revi

ew

07/10/2019

Effective: 08/24/200

Next Review:

05/08/2020

Review Hi

story

Definitions

Additional Information

Number: 0482

Policy *Please see amendment for Pennsylvania Medicaid 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)

II. Edema accompanying paraplegia, quadriplegia, etc.

http://www.aetna.com/cpb/medical/data/400_499/0482.html

https://www.aetna.com/


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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, 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 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.



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****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.

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



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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 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



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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 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 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



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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 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



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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 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).



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However, a main 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.

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

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



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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 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.

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 "+":



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Code Code Description

HCPCS codes covered if selection criteria are met:

A4465 Non-elastic binder for extremity

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:

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

I89.0 - I89.9

I95.1

O90.89

Q82.0

R60.0 - R60.9

Z74.01

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

I70.201 -

I70.299

I70.301 -

I70.799

I74.2 - I74.4

I77.1

I77.89

M79.18

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The above policy is based on the following references:

1. Herouy Y. Lipodermatosclerosis and compression stockings. J Am Acad

Dermatol. 2000;42(2 Pt 1):307-308.

2. Agnelli G, Sonaglia F. Prevention of venous thromboembolism. Thromb

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



Page 13 of 17

3. Clement DL. Management of venous edema: Insights from an

international task force. Angiology. 2000;51(1):13-17.

4. Freedman MD. Clinical therapeutic conference: Recurrent venous

thrombotic and thromboembolic disease. Am J Ther. 1998;5(1):51-56.

5. Agu O, Hamilton G, Baker D. Graduated compression stockings in the

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

6. 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.

7. Baker S, Fletcher A, Glanville J, et al. Compression therapy for venous leg

ulcers. Effective Health Care. 1997;3(1).

8. Phillips TJ. Successful methods of treating leg ulcers. The tried and true,

plus the novel and new. Postgrad Med. 1999;105(5):159-161, 165-166, 173-

174 passim.

9. Neumann HA. Compression therapy with medical elastic stockings for

venous diseases. Dermatol Surg. 1998;24(7):765-770.

10. Greer IA. Epidemiology, risk factors and prophylaxis of venous thrombo-

embolism in obstetrics and gynaecology. Baillieres Clin Obstet Gynaecol.

1997;11(3):403-430.

11. Veraart JC, Daamen E, de Vet HC, et al. Elastic compression stockings:

Durability of pressure in daily practice. Vasa. 1997;26(4):282-286.

12. Mohr DN, Silverstein MD, Murtaugh PA, et al. Prophylactic agents for

venous thrombosis in elective hip surgery. Meta-analysis of studies using

venographic assessment. Arch Intern Med. 1993;153(19):2221-2228.

13. Alguire PC, Mathes BM. Chronic venous insufficiency and venous

ulceration. J Gen Intern Med. 1997;12(6):374-383.

14. 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.

15. Yashura H, Shigematsu, H, Muto T. A study of the advantages of elastic

stockings for leg lymphedema. Int Angiol. 1996;15(3):272-277.

16. Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous

thromboembolism following total hip replacement. JAMA. 1994;271

(22):1780-1785.

17. Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the

prevention of postoperative venous thromboembolism. Arch Intern Med.

1994;154(1):67-72.



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18. Trinity Lymphedema Centers. LegAssist Non-Elastic Adjustable Limb

Containment System [website]. Tampa, FL: Trinity Lymphedema Centers;

2002. Available at: http://www.trinitylc.com/cmpgarm1.html. Accessed

April 26, 2002.

19. Leduc O, Leduc A. Rehabilitation protocol in upper limb lymphedema. Ann

Ital Chir. 2002;73(5):479-484.

20. Spence RK, Cahall E. Inelastic versus elastic leg compression in chronic

venous insufficiency: A comparison of limb size and venous

hemodynamics. J Vasc Surg. 1996; 24(5):783-787.

21. 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.

22. Lund E. Exploring the use of CircAid(R) legging in the management of

lymphoedema. Int J Palliat Nurs. 2000; 6(8):383-391.

23. O'Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers.

Cochrane Database Syst Rev. 2009;(1):CD000265.

24. Nelson EA, Bell-Syer SEM, Cullum NA. Compression for preventing

recurrence of venous ulcers. Cochrane Database Syst Rev. 2000;

(4):CD002303.

25. Kolbach DN, Sandbrink MWC, Hamulyak K, et al. Non-pharmaceutical

measures for prevention of post-thrombotic syndrome. Cochrane

Database Syst Rev. 2003;(3):CD004174.

26. Kolbach DN, Sandbrink MWC, Neumann HAM, Prins MH. Compression

therapy for treating stage I and II (Widmer) post-thrombotic syndrome.

Cochrane Database Syst Rev. 2003;(4):CD004177.

27. Amaragiri SV, Lees TA. Elastic compression stockings for prevention of

deep vein thrombosis. Cochrane Database Syst Rev. 2000;(1):CD001484.

28. CIGNA HealthCare Medicare Administration. Coverage of compression

garments in the treatment of venous stasis ulcers. CMS News and

Information. Philadelphia, PA: CIGNA; July 15, 2003.

29. Velmahos GC, Kern J, Chan L, et al. Prevention of venous

thromboembolism after injury. Evidence Report/Technology Assessment

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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 © 2001-2019 Aetna Inc.



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 07/09/2019

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission A ...€¦ · The above reference to inflatable compression garments (e.g., Flowtron Compression Garment, Jobst Pneumatic Compressor)