Rule 5160-10-17 | DMEPOS: pneumatic compression devices and accessories.
(A) Payment may be made directly to a provider for a pneumatic compressor or a related appliance or accessory only if the following conditions are satisfied:
(1) The equipment is used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous stasis ulcers; and
(2) The prescribing practitioner has determined either that there was no significant improvement or that significant symptoms persisted when one of the following treatments was applied:
(a) For lymphedema in the extremities, four weeks of therapy involving the use of an appropriate compression bandage system or compression garment (either prefabricated or custom-fabricated), exercise, and elevation of the limb; or
(b) For CVI, six months of therapy involving the use of an appropriate compression bandage system or compression garment, appropriate wound dressings, exercise, and elevation of the limb.
(B) Pneumatic compression devices to be used to treat conditions of the chest or trunk are not covered.
(C) The provider of the pneumatic compression device is expected to obtain from the prescribing practitioner brief documentation of the need for the device and to keep this documentation on file. Use of form ODM 02929 (rev. 7/2018) for this purpose is permitted but not obligatory. The documentation should include the following information as applicable:
(1) A statement that previous treatment produced no significant improvement or that significant symptoms persisted;
(2) The date of the most recent evaluation;
(3) Identification by diagnosis code of the condition or conditions necessitating a pneumatic compression device;
(4) The expected length of time (expressed as the number of months or as 'lifetime') during which the individual will need the pneumatic compression device;
(5) A listing of symptoms observed, measurements taken, and any other data that serve to establish the severity of the condition or conditions;
(6) Specification of the pneumatic compression device and any accessories to be supplied;
(7) Documentation of the individual's clinical response to treatment during evaluation (including changes in measurement results);
(8) A brief summary of the treatment plan, including the pressure to be used, the frequency and duration of use, and a provisional monitoring schedule;
(9) An assessment of the individual's capacity for tolerating the prescribed treatment; and
(10) A statement about the ability of the individual (or someone authorized to assist the individual) to use the device correctly and consistently.
(D) For a covered pneumatic compressor, payment may be made for short-term rental (repeated as necessary for not more than a total of ten months), for rental with subsequent purchase, or for purchase outright, as the prescribing practitioner determines to be appropriate. For a covered pneumatic appliance or accessory, payment is made for purchase.
Last updated January 2, 2024 at 8:58 AM
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