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Pneumatic compression devices consist of an inflatable garment and an electrical pneumatic controller or pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures to improve venous circulation and lymphatic drainage. This treatment is also referred to as intermittent pneumatic compression (IPC).
Pneumatic compression devices are used in the treatment of lymphedema, chronic venous insufficiency and for prevention of venous thromboembolism after major surgery. This policy addresses use of pneumatic compression devices in the home and outpatient settings.
Many different pneumatic compression devices are available, with varying materials, design, and complexity. These devices are classified into three types:
Non-programmable devices cleared by the Food and Drug Administration (FDA) for primary or adjunctive (e.g., post mastectomy) treatment of lymphedema include but are not limited to:
Programmable devices include but are not limited to:
Non-programmable devices listed above are also indicated for treatment of venous statis ulcers. Programmable devices for treatment of venous statis ulcers include but are not limited to:
FDA-cleared devices with indications that include prevention of deep vein thrombosis (DVT) include, but are not limited to, the following:
Definitions
Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as surgical removal of lymph nodes or post radiation fibrosis, among other causes.
Chronic venous insufficiency (CVI) of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.
Venous thromboembolism (VTE) refers to deep vein thrombosis (DVT) or pulmonary embolism (PE). Risk of DVT increases due to venous stasis of the lower limbs as a consequence of immobility during or after surgery. Patients who have major orthopedic surgery (such a total hip arthroplasty, total knee arthroplasty and hip fracture surgery) are at particularly high risk. While most DVTs are asymptomatic and generally resolve when mobility is restored, some acute DVTs can be associated with substantial morbidity. The most serious adverse consequence of an acute DVT is a PE, which occurs when a DVT detaches and migrates to the lungs. Antithrombotic prophylaxis is recommended for patients undergoing major orthopedic surgery and for other surgical patients at increased risk of VTE. Specialty society guidelines recommend pharmacotherapy unless it is contraindicated.
I. Lymphedema
The use of segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of lymphedema of the upper or lower limbs in the outpatient or home setting when ALL of the following criteria are met:
The use of segmented pneumatic compression therapy devices with calibrated gradient pressure (programmable pumps) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of lymphedema of the upper or lower limbs in the outpatient or home setting when the patient meets criteria for a device without calibrated gradient pressure (non-programmable pumps) and either of the following criteria are met:
II. Chronic Venous Insufficiency
The use of segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of chronic venous insufficiency of the lower extremities in the outpatient or home setting when ALL of the following criteria are met:
The use of segmented pneumatic compression therapy devices with calibrated gradient pressure (programmable pumps) may be considered MEDICALLY NECESSARY AND APPROPRIATE for the treatment of chronic venous insufficiency of the lower extremities in the outpatient or home setting when the patient meets criteria for a device without calibrated gradient pressure (non-programmable pumps) and either of the following criteria are met:
III. Post-Surgical Venous Thromboembolism (VTE) Prophylaxis
The use of pneumatic compression devices in the outpatient or home setting may be considered MEDICALLY NECESSARY AND APPROPRIATE in patients who have undergone a surgical procedure when BOTH 1 and 2 are met:
Outpatient or home use of pneumatic compression devices for post-surgical VTE prophylaxis is considered NOT MEDICALLY NECESSARY AND APPROPRIATE for patients who have undergone a surgical procedure with a low risk of VTE and who have no additional risk factors for VTE. Examples of lower risk surgical procedures include, but are not limited to, laparoscopic cholecystectomy, appendectomy, transurethral prostatectomy, and inguinal herniorrhaphy.
IV. Experimental/Investigative Uses
The use of pneumatic compression devices in the outpatient or home setting is considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating its impact on improved health outcomes for all other indications, including but not limited to:
No additional statements.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
