Compression Garments for the Legs - Medical Clinical Policy Bulletins | Aetna Page 1 of 24
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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
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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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Code Code Description
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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Code Code Description
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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Code Code Description
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
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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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