Medical Policies Online - Policy #: 05.00.37c

Medical Policy Bulletin

Title:

Compression Garments

Policy #:

05.00.37c

The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's coverage and reimbursement position for compression garments.

For information on policies related to this topic, refer to the Cross References Table in this policy.

Description

Compression garments are two-way stretch knit fabrics that are worn over an area of the body. They can be used to treat burns, lymphedema, or various venous stasis ulcers; to prevent clots; and/or to provide general comfort. The stretch and resistance of the garments, together with the natural movement of muscles and blood vessels during normal activity, help with circulation and increase the effectiveness of lymphatic vessels, thus reducing edema and pain.
Compression garments are available and prescribed to be used for specific parts of the body (eg, glove-to-axilla, foot-to-knee, or upper/lower trunk), and stockings are available in varying pressures and lengths (eg, waist length, thigh length, full length, and below-the-knee).

TYPES OF COMPRESSION GARMENTS

BURN GARMENTS
Compression burn garments (eg, bodysuits and leotards) help burns to heal with less scarring by applying pressure and flattening the burn area. They also protect the skin, promote circulation within the damaged tissues, and decrease pain and itching.

LYMPHEDEMA GARMENTS
A compression garment that is used in lymphedema therapy is referred to as a gradient pressure aid. Gradient pressure aids (eg, gloves, gauntlets, and sleeves) help to control the excessive accumulation of lymphatic fluid in an upper extremity.

GRADIENT COMPRESSION STOCKINGS
Gradient compression stockings (eg, Jobst stockings) can be used to treat chronic venous insufficiency and lymphedema and to prevent and treat venous stasis ulcers. These stockings deliver pressure to the leg that is tightest at the ankle, with the amount of compression gradually decreasing as the stocking moves up the leg.

GRADIENT COMPRESSION WRAPS
Non-elastic gradient compression wraps work in a similar manner to compression stockings and are used in the treatment of open venous stasis ulcers.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic deterrent [TED]) stockings are typically used for individuals during a hospitalization that requires bed confinement or during a postsurgery recuperation period. These stockings can also be used to help prevent leg fatigue and the discomfort associated with varicose veins. Antiembolism stockings offer equalized compression throughout the stocking, while gradient compression stockings offer graduated pressure throughout the stocking. Antiembolism stockings do not require a physician's prescription and can be purchased over the counter.

Policy

The requirements for the coverage of compression garments for commercial and Medicare Advantage members are as follows:

COMMERCIAL MEMBERS

BURN AND LYMPHEDEMA GARMENTS
Burn and lymphedema garments are considered medically necessary and, therefore, covered when one of the following medical necessity criteria is met:

When a compression burn garment (Healthcare Common Procedure Coding System [HCPCS] codes A6501-A6513) is prescribed following a burn injury
When a gradient pressure aid (eg, a glove or gauntlet) (HCPCS codes S8420-S8428) or a mastectomy sleeve (HCPCS code L8010) is prescribed as part of a postmastectomy lymphedema program

GRADIENT COMPRESSION STOCKINGS
Gradient compression stockings (eg, Jobst stockings) (HCPCS codes A6530-A6549) are considered medically necessary and, therefore, covered when they are prescribed by a physician to treat conditions including, but not limited to, chronic venous insufficiency and lymphedema and to prevent and treat venous stasis ulcers.

Limitations of coverage for gradient compression stockings are as follows: Coverage is limited to 12 individual gradient compression stockings (or six pairs of stockings if the individual requires the stockings for both lower extremities) (HCPCS codes A6530-A6549) within a calendar year. Additional stockings are considered not medically necessary and, therefore, not covered.

GRADIENT COMPRESSION WRAPS
Gradient compression wraps (HCPCS code A6545) are considered medically necessary and, therefore, covered when used in the treatment of an open venous stasis ulcer. Coverage is limited to one below-the-knee gradient compression wrap per leg per six months. Additional wraps are considered not medically necessary and, therefore, not covered.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thrombo-embolic deterrent [TED]) stockings (HCPCS codes A4490-A4510) are considered medically necessary and, therefore, covered when they are used to prevent and/or treat conditions such as, but not limited to, deep vein thrombosis.

Limitations of coverage for antiembolism stockings are as follows: Coverage is limited to 12 individual antiembolism stockings (or six pairs of stockings if the individual requires the stockings for both lower extremities) (HCPCS codes A4490-A4510) within a calendar year. Additional stockings are considered not medically necessary and, therefore, not covered.

MEDICARE ADVANTAGE MEMBERS

BURN AND LYMPHEDEMA GARMENTS
Burn garments are considered medically necessary and, therefore, covered when a compression burn garment (HCPCS codes A6501-A6513) is prescribed following a burn injury.

Lymphedema garments, such as gradient pressure aids (eg, a glove or gauntlet) (HCPCS codes S8420-S8428) and mastectomy sleeves (HCPCS code L8010) are not covered by Medicare and, therefore, are not eligible for reimbursement for Medicare Advantage members.

GRADIENT COMPRESSION STOCKINGS
Below-the-knee gradient compression stockings (eg, Jobst stockings) with pressure between 30 mm Hg and 50 mm Hg (HCPCS codes A6531 and A6532) are considered medically necessary and, therefore, covered when the stocking is used to secure a primary dressing over a debrided venous stasis ulcer.

All other gradient compression stockings (HCPCS codes A6530 and A6533-A6549) are not covered by Medicare and, therefore, are not eligible for reimbursement consideration for Medicare Advantage members.

GRADIENT COMPRESSION WRAPS
Gradient compression wraps (HCPCS code A6545) are considered medically necessary and, therefore, covered when used in the treatment of an open venous stasis ulcer. Coverage is limited to one below-the-knee gradient compression wrap per leg per six months. Additional wraps are considered not medically necessary and, therefore, not covered.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or TED) stockings are not covered by Medicare and, therefore, are not eligible for reimbursement consideration for Medicare Advantage members.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

An order for each item billed must be signed and dated by the health care professional who is treating the member and kept on file by the supplier. Medical record documentation must include a shipment confirmation or member's receipt of supplies and equipment. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, compression garments are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

MEDICARE

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

MANDATES

This policy is consistent with federal and state mandates.

References

American Cancer Society (ACS). Women's Health and Cancer Rights Act. [ACS Web site]. 08/11/08. Available at: http://www.cancer.org/docroot/MIT/content/MIT_3_2X.asp. Accessed February 26, 2009.

Centers for Medicare & Medicaid Services (CMS). Article for coverage of compression garments in the treatment of venous stasis ulcers (A10116). [CMS Web site]. Original: 09/01/03. (Revised: 06/01/07). Available at: http://www.cms.hhs.gov/mcd/viewarticle.asp?article_id=10116&article_version=4&show=all. Accessed February 26, 2009.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 270.5: Porcine skin and gradient pressure dressings. [CMS Web site]. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=270.5&ncd_version=1&basket=ncdpercent3A270percent2E5percent3A1percent3APorcine+Skin+and+Gradient+Pressure+Dressings. Accessed February 26, 2009.

Company Benefit Contracts.

National Heritage Insurance Company (NHIC). HCPCS jurisdiction list. [NHIC Web site]. 10/27/08. Available at: http://www.medicarenhic.com/dme/medical_review/mr_hcpcs/2008_hcpcs_jurisdiction_list.pdf. Accessed February 26, 2009.

National Heritage Insurance Company (NHIC). Local Coverage Determination (LCD). L11471: Surgical dressings. [NHIC Web site]. Original: 10/01/93. (Revised: 01/01/09). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11471_2009-01-01_PA_2009-01.pdf. Accessed February 26, 2009.

National Heritage Insurance Company (NHIC). Surgical dressings billing instruction for HCPCS code A6545. [NHIC Web site]. 12/26/08. Available at: http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_current/122608_a6545.pdf. Accessed February 26, 2009.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	454.0: Varicose veins of lower extremities with ulcer 454.2: Varicose veins of lower extremities with ulcer and inflammation 457.0: Postmastectomy lymphedema syndrome 457.1: Other noninfectious lymphedema 459.81: Unspecified venous (peripheral) insufficiency 707.10: Ulcer of lower limb, unspecified 707.12: Ulcer of calf 707.13: Ulcer of ankle 707.14: Ulcer of heel and midfoot 707.15: Ulcer of other part of foot 707.19: Ulcer of other part of lower limb 707.8: Chronic ulcer of other specified site 707.9: Chronic ulcer of unspecified site 941.00: Burn of unspecified degree of unspecified site of face and head 941.01: Burn of unspecified degree of ear (any part) 941.02: Burn of unspecified degree of eye (with other parts of face, head, and neck) 941.03: Burn of unspecified degree of lip(s) 941.04: Burn of unspecified degree of chin 941.05: Burn of unspecified degree of nose (septum) 941.06: Burn of unspecified degree of scalp (any part) 941.07: Burn of unspecified degree of forehead and cheek 941.08: Burn of unspecified degree of neck 941.09: Burn of unspecified degree of multiple sites (except with eye) of face, head, and neck 942.00: Burn of unspecified degree of trunk, unspecified site 942.01: Burn of trunk, unspecified degree of breast 942.02: Burn of trunk, unspecified degree of chest wall, excluding breast and nipple 942.03: Burn of trunk, unspecified degree of abdominal wall 942.04: Burn of trunk, unspecified degree of back (any part) 942.05: Burn of trunk, unspecified degree of genitalia 942.09: Burn of trunk, unspecified degree of other and multiple sites 943.00: Burn of unspecified degree of unspecified site of upper limb 943.01: Burn of unspecified degree of forearm 943.02: Burn of unspecified degree of elbow 943.03: Burn of unspecified degree of upper arm 943.04: Burn of unspecified degree of axilla 943.05: Burn of unspecified degree of shoulder 943.06: Burn of unspecified degree of scapular region 943.09: Burn of unspecified degree multiple sites of upper limb, except wrist and hand 944.00: Burn of unspecified degree of unspecified site of hand 944.01: Burn of unspecified degree of single digit [finger (nail)] other than thumb 944.02: Burn of unspecified degree of thumb (nail) 944.03: Burn of unspecified degree of two or more digits of hand, not including thumb 944.04: Burn of unspecified degree of two or more digits of hand, including thumb 944.05: Burn of unspecified degree of palm of hand 944.06: Burn of unspecified degree of back of hand 944.07: Burn of unspecified degree of wrist 944.08: Burn of unspecified degree of multiple sites of wrist(s) and hand(s) 945.00: Burn of unspecified degree of unspecified site of lower limb (leg) 945.01: Burn of unspecified degree of toe(s) (nail) 945.02: Burn of unspecified degree of foot 945.03: Burn of unspecified degree of ankle 945.04: Burn of unspecified degree of lower leg 945.05: Burn of unspecified degree of knee 945.06: Burn of unspecified degree of thigh (any part) 945.09: Burn of unspecified degree of multiple sites of lower limb(s) 948.00: Burn (any degree) involving less than 10 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.10: Burn (any degree) involving 10-19 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.11: Burn (any degree) involving 10-19 percent of body surface with third degree burn of 10-19 percent 948.20: Burn (any degree) involving 20-29 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.21: Burn (any degree) involving 20-29 percent of body surface with third degree burn of 10-19 percent 948.22: Burn (any degree) involving 20-29 percent of body surface with third degree burn of 20-29 percent 948.30: Burn (any degree) involving 30-39 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.31: Burn (any degree) involving 30-39 percent of body surface with third degree burn of 10-19 percent 948.32: Burn (any degree) involving 30-39 percent of body surface with third degree burn of 20-29 percent 948.33: Burn (any degree) involving 30-39 percent of body surface with third degree burn of 30-39 percent 948.40: Burn (any degree) involving 40-49 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.41: Burn (any degree) involving 40-49 percent of body surface with third degree burn of 10-19 percent 948.42: Burn (any degree) involving 40-49 percent of body surface with third degree burn of 20-29 percent 948.43:Burn (any degree) involving 40-49 percent of body surface with third degree burn of 30-39 percent 948.44: Burn (any degree) involving 40-49 percent of body surface with third degree burn of 40-49 percent 948.50: Burn (any degree) involving 50-59 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.51: Burn (any degree) involving 50-59 percent of body surface with third degree burn of 10-19 percent 948.52: Burn (any degree) involving 50-59 percent of body surface with third degree burn of 20-29 percent 948.53: Burn (any degree) involving 50-59 percent of body surface with third degree burn of 30-39 percent 948.54: Burn (any degree) involving 50-59 percent of body surface with third degree burn of 40-49 percent 948.55: Burn (any degree) involving 50-59 percent of body surface with third degree burn of 50-59 percent 948.60: Burn (any degree) involving 60-69 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.61: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 10-19 percent 948.62: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 20-29 percent 948.63: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 30-39 percent 948.64: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 40-49 percent 948.65: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 50-59 percent 948.66: Burn (any degree) involving 60-69 percent of body surface with third degree burn of 60-69 percent 948.70: Burn (any degree) involving 70-79 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.71: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 10-19 percent 948.72: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 20-29 percent 948.73: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 30-39 percent 948.74: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 40-49 percent 948.75: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 50-59 percent 948.76: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 60-69 percent 948.77: Burn (any degree) involving 70-79 percent of body surface with third degree burn of 70-79 percent 948.80: Burn (any degree) involving 80-89 percent of body surface with third degree burn of less than 10 percent or unspecified amount 948.81: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 10-19 percent 948.82: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 20-29 percent 948.83: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 30-39 percent 948.84: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 40-49 percent 948.85: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 50-59 percent 948.86: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 60-69 percent 948.87: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 70-79 percent 948.88: Burn (any degree) involving 80-89 percent of body surface with third degree burn of 80-89 percent 948.90: Burn (any degree) involving 90 percent or more of body surface with third degree burn of less than 10 percent or unspecified amount 948.91: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 10-19 percent 948.92: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 20-29 percent 948.93: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 30-39 percent 948.94: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 40-49 percent 948.95: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 50-59 percent 948.96: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 60-69 percent 948.97: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 70-79 percent 948.98: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 80-89 percent 948.99: Burn (any degree) involving 90 percent or more of body surface with third degree burn of 90 percent or more of body surface 949.0: Burn of unspecified site, unspecified degree
HCPCS Level II	For commercial (non-Medicare Advantage) members, refer to Attachment A for applicable HCPCS codes. For Medicare Advantage members, refer to Attachment B for applicable HCPCS codes.
Revenue Codes	N/A

Cross References

Associated attachments to Policy 05.00.37c: Compression Garments

	Attachment A: Compression Garments Description: Contains the applicable HCPCS codes for compression garments for commercial (non-Medicare Advantage) members
	Attachment B: Compression Garments Description: Contains the applicable HCPCS codes for compression garments for Medicare Advantage members

Cross Reference Policies

05.00.01f:

Pneumatic Compression Therapy Devices

07.06.01a:Decongestive Lymphedema Therapy (DLT)

11.02.01h:Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

Version Effective Date: 01/01/2010