Medical Policy Update

New Medical Policies

Medical Policy Pneumatic Pumps (programmable and nonprogrammable) 

1. Single-compartment or multichamber nonprogrammable lymphedema pumps applied to the limb may be considered medically necessary for the treatment of lymphedema when:
   1. The individual has diagnosis of:
      1. Lymphedema of the extremities, OR
      2. Edema for any reason of the extremities i.e. (after trauma/surgery/post DVT/pregnancy/post sclerotherapy), OR
      3. Prevention of thrombosis.
2. Single-compartment or multichamber programmable lymphedema pumps applied to the limb may be considered medically necessary for the treatment of lymphedema when:
   1. The individual has diagnosis of:
      1. Lymphedema of the extremities, OR
      2. Edema for any reason of the extremities i.e. (after trauma/surgery/post DVT/pregnancy/post sclerotherapy), OR
      3. Prevention of thrombosis.
         AND
   2. There is documentation that the individual has unique characteristics (e.g., significant scarring) that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable lymphedema pumps.
3. Single-compartment or multichamber programmable lymphedema pumps applied to the limb are considered investigational in all situations other than those specified above Including:
   1. Use of pneumatic pumps to treat the trunk or chest without involvement of the extremities, OR
   2. Pneumatic pumps applied to the head and neck, OR
   3. Pneumatic pumps for treatment of venous ulcers.