Medicare Advantage

Medical Policy

Notification

Compression Garments

Notification Issued Date:

The policy has been reviewed and reissued to communicate the Company’s continuing position on compression garments.

Title:

Compression Garments

Policy #:

MA05.045e

Policy

MEDICALLY NECESSARY

COMPRESSION BURN GARMENTS
Compression burn garments are considered medically necessary and, therefore, covered when a compression burn garment is prescribed following a burn injury.

DAYTIME COMPRESSION GARMENTS

Daytime compression garments (e.g., stockings, wraps, sleeves, gloves, gauntlets toe caps, torso [bras, binders, vests]) are considered medically necessary and, therefore, covered when prescribed as part of a complete decogngestive therapy (CDT) program for lymphedema for a maximum number of six garments per each affected area in a 12-month period.

GRADIENT COMPRESSION SURGICAL DRESSING WRAPS/STOCKINGS

Gradient compression surgical dressing non-elastic wraps with a pressure between 30 to 50 mm Hg are considered medically necessary and, therefore, covered when prescribed for open venous stasis ulcers and/or surgically created wounds for a maximum number of two garments per each leg in a 12-month period.

Gradient compression surgical dressing stockings with a pressure between 30 to 50 mm Hg are considered medically necessary and, therefore, covered when prescribed for open venous stasis ulcers and/or surgically created wounds.

NIGHTTIME COMPRESSION GARMENTS

Nighttime compression garments (e.g., non-elastic gloves and torso garments [bras, binders, vests], and non-elastic garments for upper and lower extremities) are considered medically necessary and, therefore, covered when prescribed as part of a CDT program for lymphedema for a maximum number of one garment per each affected area in a 12-month period.

ACCESSORIES AND BANDAGING ROLLS/SUPPLIES

Accessories and bandaging supplies (e.g., aids for applying and removing garments, fillers, lining, padding, zippers) for the appropriate use of a compression garment are considered medically necessary and, therefore, covered when prescribed for lymphedema compression garments.

NOT COVERED

Compression garments that exceed the established frequency limits are not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

All other uses of gradient compression garments are not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Antiembolism (surgical or thrombo-embolic-deterrent [TED]) stockings are not covered by Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement.

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 be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

Guidelines

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, compression garments are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified as noncovered are not eligible for coverage reimbursement by the Company.

Description

Compression garments are typically 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 (e.g., glove-to-axilla, foot-to-knee, or upper/lower trunk), and stockings are available in varying pressures and lengths (e.g., waist length, thigh length, full length, and below-the-knee). They typically fall within four different categories: Circular knit (i.e., “ready to wear"), flat knit (i.e., “made-to-measure"), inelastic adjustable wraps, and nighttime garments. Made-to-measure, or custom fitted, gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression treatment for lymphedema or burn injuries. Some examples where a custom-fitted garment may be appropriate (not all-inclusive) include:

If the circumference of the proximal portion of the limb is significantly greater than the distal limb
If the skin/tissue has folds or contours requiring a specific type of knitting pattern
Beneficiary is unable to tolerate the fabric composition of the standard garment

A nonoperative standard of care for peripheral lymphedema is an individualized approach comprising complete decongestive therapy (CDT). CDT generally includes manual lymphatic drainage, multilayer short stretch compression bandaging, daytime and nighttime compression garments, exercise, and the adjunctive use of pneumatic compression. Various professional societies including the International Society of Lymphology, American Venous Forum, American Vein and Lymphatic Society, and the Society for Vascular Medicine support the use of compression garments as part of a CDT program based on expert consensus and evidence-based practice.

TYPES OF COMPRESSION GARMENTS

BURN GARMENTS
Compression burn garments (e.g., stockings, 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, VENOUS STASIS ULCER, AND SURGICALLY CREATED WOUND GARMENTS

Gradient Compression Garments and Dressings for Lower Extremities

Daytime gradient compression garments for the lower extremities (e.g., stockings, full-length chaps) are used to control the excessive accumulation of lymphatic fluid in the legs of individuals with lymphedema. These garments 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 garments for the lower extremities are available in a variety of pressure levels (e.g., 18-30 mm Hg, 30-40 mm Hg, 40-50 mm Hg).

Gradient compression wraps work in a similar manner as, and can be an alternative to, gradient compression stockings. These garments are non-elastic and can be used for the treatment of lymphedema. Wraps can also be used as a surgical dressing in the treatment of open venous stasis ulcers and surgically created wounds. An example of a gradient compression wrap is the Circaid Juxta-Lite™ (Circaid Medical Products, Inc., San Diego, CA), which is a garment composed of a series of adjustable bands, allowing the individual to modify the pressure level as needed.

Gradient Compression Garments for Upper Extremities

Similarly to lower extremity garments, daytime gradient compression garments (e.g., gloves, gauntlets, sleeves) for the upper extremities are used to control the progressive accumulation of lymphatic fluid in the arms and hands using various pressure levels ranging from 20 to 40 mm Hg. The length of a knitted sleeve gradually increases from the wrist to the upper portion of the sleeve.

Gradient Compression and Non-Elastic Garments for the Torso
Additional daytime compression garments that are commercially available include those for the treatment of lymphedema of the torso. An example is the JoVi Vest® (JoVi PAK, Kent, WA). According to the manufacturer, the JoViVest® is offered as a made-to-order or custom-fabricated garment and can be prescribed to address chest wall edema and fibrosis. For truncal and chest edema, manual lymphatic drainage (MLD), performed by an experienced professional provider, is a generally accepted standard medical practice, often followed by compression garments as part of CDT program.

Non-elastic binders are composed of material that is fastened with adjustable velcro, hooks, loops, or other straps to provide compression. They apply a gentle gradient compression to the extremity, with some models equipped with gauges that assess the applied pressure over the upper or lower extremity. The gauges provide the assurance that the amount of compression is consistently applied across the extremity. Non-elastic binders are used in the treatment of conditions that include lymphedema and chronic venous insufficiency. Examples include Circaid® JuxtaFit™ Essentials (CircAid Medical Products, Inc., San Diego, CA); ArmAssist® and LegAssist® (BiaCare, Zeeland, MI); and ReidSleeve® Classic Arm and ReidSleeve® Classic Leg (Peninsula Medical, Inc., Scotts Valley, CA).

Alternate Gradient Compression Garments

The excessive accumulation of lymphatic fluid can occur throughout the body due to a blockage or damage to the lymph system. While swelling most commonly occurs in the arm or leg, a variety of garments exist for the treatment of lymphedema in other body areas such as but not limited to the neck, head, genital, and foot regions.

Nighttime Compression Garments

Individuals with more severe forms of lymphedema may require compression during the day and at nighttime to effectively manage their lymphedema. Some daytime garments, particularly those with elastic components, are utilized when the individual is active and can provide too much compression at times when the individual is sedentary or asleep. An option for the nighttime management of lymphedema is nighttime garments. Nighttime compression garments are non-elastic and provide gentle gradient pressure to the limb through a garment with a foam liner and a series of adjustable straps. Because of their inelastic components, nighttime garments do not break down with wear as quickly as traditional daytime garments.

Accessories and Bandaging Rolls/Supplies

A wide range and variety of accessories and bandaging supplies are readily available for the effective use of garments and wraps, including but not limited to zippers, linings, padding, and fillers that may be necessary for the effective use of a lymphedema compression treatment item. They may be part of the garment as furnished or worn underneath a compression garment or wrap.

ANTIEMBOLISM STOCKINGS
Antiembolism (surgical or thromboembolic 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.

References

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 01/01/2020. Available at:https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis. Accessed August 31, 2023.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Calendar Year (CY) 2024 Home health (HH) prospective payment system rate update; HH quality reporting program requirements; HH value-based purchasing expanded model requirements; home intravenous immune globulin items and services; Hospice informal dispute resolution and special focus program requirements, certain requirements for durable medical equipment prosthetics and orthotics supplies; and provider and supplier enrollment requirements. Final Rule CMS-1780-F. [Federal Register Web site]. 01/01/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2023-11-13/pdf/2023-24455.pdf. Accessed December 20, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Porcine Skin and Gradient Pressure Dressings (270.5). [CMS website]. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAgAAAAAAA&. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A52478 External Breast Prostheses. [Noridian Health Care Solutions]. Original: 10/01/2015. (Revised 01/01/2020). Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52478&ver=20&DocID=A52478&bc=gAAAAAgAAAAA&. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Article (LCA) A54563 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised 05/01/2021). Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54563&ver=24&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Surgical+Dressings&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33317 External Breast Prostheses. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 01/01/20). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/External+Breast+Prostheses+LCD+and+PA. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33831 Surgical Dressings. [Noridian Health Care Solutions Web site]. Original: 10/01/15. (Revised: 01/01/2024). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=30&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Surgical+Dressings&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed August 31, 2023.

Noridian Health Care Solutions, LLC. Medical Director Articles. Lymphedema Compression Treatment Items - Correct Coding and Billing. Original: 12/8/2023. Available at: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/2023/lymphedema-compression-treatment-items-correct-coding-and-billing. Accessed December 20, 2023.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

COMPRESSION GARMENTS FOR TREATMENT OF BURNS

A6501 Compression burn garment, bodysuit (head to foot), custom fabricated

A6502 Compression burn garment, chin strap, custom fabricated

A6503 Compression burn garment, facial hood, custom fabricated

A6504 Compression burn garment, glove to wrist, custom fabricated

A6505 Compression burn garment, glove to elbow, custom fabricated

A6506 Compression burn garment, glove to axilla, custom fabricated

A6507 Compression burn garment, foot to knee length, custom fabricated

A6508 Compression burn garment, foot to thigh length, custom fabricated

A6509 Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated

A6510 Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated

A6511 Compression burn garment, lower trunk including leg openings (panty), custom fabricated

A6512 Compression burn garment, not otherwise classified

COMPRESSION GARMENTS FOR TREATMENT OF LYMPHEDEMA
A4465 Nonelastic binder for extremity

A6520 Gradient compression garment, glove, padded, for nighttime use, each

A6521 Gradient compression garment, glove, padded, for nighttime use, custom, each

A6522 Gradient compression garment, arm, padded, for nighttime use, each

A6523 Gradient compression garment, arm, padded, for nighttime use, custom, each

A6524 Gradient compression garment, lower leg and foot, padded, for nighttime use, each

A6525 Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each

A6526 Gradient compression garment, full leg and foot, padded, for nighttime use, each

A6527 Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each

A6528 Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6529 Gradient compression garment, bra, for nighttime use, custom, each

A6530 Gradient compression stocking, below knee, 18-30 mm Hg, each

A6533 Gradient compression stocking, thigh length, 18-30 mm Hg, each

A6534 Gradient compression stocking, thigh length, 30-40 mm Hg, each

A6535 Gradient compression stocking, thigh length, 40 mm Hg or greater, each

A6536 Gradient compression stocking, full-length/chap style, 18-30 mm Hg, each

A6537 Gradient compression stocking, full-length/chap style, 30-40 mm Hg, each

A6538 Gradient compression stocking, full length/chap style, 40 mm Hg or greater, each

A6539 Gradient compression stocking, waist length, 18-30 mm Hg, each

A6540 Gradient compression stocking, waist length, 30-40 mm Hg, each

A6541 Gradient compression stocking, waist length, 40 mm Hg or greater, each

A6544 Gradient compression stocking, garter belt

A6549 Gradient compression garment not otherwise specified

A6552 Gradient compression stocking, below knee, 30-40 mmhg, each

A6553 Gradient compression stocking, below knee, 30-40 mmhg, custom, each

A6554 Gradient compression stocking, below knee, 40 mmhg or greater, each

A6555 Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

A6556 Gradient compression stocking, thigh length, 18-30 mmhg, custom, each

A6557 Gradient compression stocking, thigh length, 30-40 mmhg, custom, each

A6558 Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

A6559 Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each

A6560 Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each

A6561 Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each

A6562 Gradient compression stocking, waist length, 18-30 mmhg, custom, each

A6563 Gradient compression stocking, waist length, 30-40 mmhg, custom, each

A6564 Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

A6565 Gradient compression gauntlet, custom, each

A6566 Gradient compression garment, neck/head, each

A6567 Gradient compression garment, neck/head, custom, each

A6568 Gradient compression garment, torso and shoulder, each

A6569 Gradient compression garment, torso/shoulder, custom, each

A6570 Gradient compression garment, genital region, each

A6571 Gradient compression garment, genital region, custom, each

A6572 Gradient compression garment, toe caps, each

A6573 Gradient compression garment, toe caps, custom, each

A6574 Gradient compression arm sleeve and glove combination, custom, each

A6575 Gradient compression arm sleeve and glove combination, each

A6576 Gradient compression arm sleeve, custom, medium weight, each

A6577 Gradient compression arm sleeve, custom, heavy weight, each

A6578 Gradient compression arm sleeve, each

A6579 Gradient compression glove, custom, medium weight, each

A6580 Gradient compression glove, custom, heavy weight, each

A6581 Gradient compression glove, each

A6582 Gradient compression gauntlet, each

A6583 Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each

A6584 Gradient compression wrap with adjustable straps, not otherwise specified

A6585 Gradient pressure wrap with adjustable straps, above knee, each

A6586 Gradient pressure wrap with adjustable straps, full leg, each

A6587 Gradient pressure wrap with adjustable straps, foot, each

A6588 Gradient pressure wrap with adjustable straps, arm, each

A6589 Gradient pressure wrap with adjustable straps, bra, each

A6593 Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6594 Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each

A6595 Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each

A6596 Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each

A6597 Gradient compression bandage roll, elastic long stretch, linear yard, any width, each

A6598 Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each

A6599 Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each

A6600 Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each

A6601 Gradient compression bandaging supply, high density foam pad, any size or shape, each

A6602 Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each

A6603 Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each

A6604 Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each

A6605 Gradient compression bandaging supply, padded foam, per linear yard, any width, each

A6606 Gradient compression bandaging supply, padded textile, per linear yard, any width, each

A6607 Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each

A6608 Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each

A6609 Gradient compression bandaging supply, not otherwise specified

A6610 Gradient compression stocking, below knee, 18-30 mmhg, custom, each

S8420 Gradient pressure aid (sleeve and glove combination), custom made

S8421 Gradient pressure aid (sleeve and glove combination), ready made

S8422 Gradient pressure aid (sleeve), custom made, medium weight

S8423 Gradient pressure aid (sleeve), custom made, heavy weight

S8424 Gradient pressure aid (sleeve), ready made

S8425 Gradient pressure aid (glove), custom made, medium weight

S8426 Gradient pressure aid (glove), custom made, heavy weight

S8427 Gradient pressure aid (glove), ready made

S8428 Gradient pressure aid (gauntlet), ready made

S8429 Gradient pressure exterior wrap

SURGICAL DRESSINGS

A6531 Gradient compression stocking, below knee, 30-40 mm Hg, used as a surgical dressing, each

A6532 Gradient compression stocking, below knee, 40-50 mm Hg, used as a surgical dressing, each

SURGICAL DRESSING WRAP
A6545 Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each

NOT COVERED

A4490 Surgical stockings above knee length, each
A4495 Surgical stockings thigh length, each
A4500 Surgical stockings below knee length, each
A4510 Surgical stockings full-length, each

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

6/3/2024

Version Issued Date: