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Lymphedema pumps consist of pneumatic cuffs that are connected to a pump. They use compressed air to apply pressure to the affected limb. The intention is to force excess lymph fluid out of the limb and into central body compartments where lymphatic drainage should be preserved. Many different pneumatic compression pumps for treating lymphedema are available, with varying materials, design, degree of pressure and complexity. There are three primary types of pumps as follows:

• Single-chamber non-programmable pumps: These are the simplest pumps and consist of a single chamber that is inflated at one time and applies uniform pressure. 
• Multi-chamber non-programmable pumps: Pumps have multiple chambers, ranging from 2 to 12 or more. The chambers are inflated sequentially and have a fixed pressure in each compartment. They can either have the same pressure in each compartment or a pressure gradient, but they do not include the ability to manually adjust the pressure in individual compartments. 
• Single- or multi-chamber programmable pumps: These are similar to the pumps described above except that it is possible to make manual adjustments in the pressure in the individual compartments and/or the length and frequency of the inflation cycles. 

Recently, a new type of pump has been introduced, a two-stage multi-chamber pump. One device of this type, the Flexitouch™ system, has 27-32 chambers and includes 13 sequential treatment programs for different regions of the body. Treatment sessions consist of 2 phases, meant to simulate manual lymph drainage. The first phase is preparation of the affected area for drainage which uses a proximal-to-distal gradient and the second phase is drainage which uses a distal-to-proximal gradient. The Flexitouch system includes a variety of garment types. For treating an upper extremity, chest and trunk garments are used in addition to the arm garment. When treating a lower extremity, a trunk garment is used with a calf-foot garment. This allows treatment of the truncal area in addition to the affected limb.

Several pneumatic compression pumps indicated for primary or adjunctive treatment of primary or secondary (e.g., post-mastectomy) lymphedema have been cleared for marketing by the FDA through the 510(k) process. Examples of devices with these indications that are intended for home or clinic/hospital use include the Compression pump, Model GS-128 (Medmark Technologies, LLC); the Sequential Circulator (BioCompression Systems, Inc.); and the Lympha-Press (Mego Afek, Israel). Device manufacturers generally have a line of products for different applications and to treat different affected areas of the body. A pump with another variation in pump design, the Flexitouch™ (Tactile Systems Technology, Inc.) was cleared by the FDA in 2006.

Related medical policies include Bioimpedence Devices for Detection of Lymphedema and End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema.  

Lymphedema pumps may be used in lymphedema clinics or purchased or rented for home use. This policy addresses the home use of lymphedema pumps.

Single compartment or multi-chamber programmable lymphedema pumps are considered medically necessary for the treatment of lymphedema when:

1. The individual is otherwise eligible for non-programmable pumps; and
2. There is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression with single-compartment or multi-chamber non-programmable lymphedema pumps (e.g., significant scarring).

Single compartment or multichamber lymphedema pumps are considered investigational in all situations other than those specified above in the first two policy statements.

The use of lymphedema pumps to treat the trunk or chest in patients with lymphedema limited to the upper and/or lower limbs is considered investigational.

The use of lymphedema pumps to treat venous ulcers is considered investigational.

Pneumatic compression devices prescribed for patients undergoing surgery as a means of prophylaxis to prevent Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) should be included in the surgical facility's claim. This does not meet the criteria for Durable Medical Equipment and may not be billed separately. It is not appropriate for providers to bill the patient for this service.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

8/1997: Revision approved by MPAC; policy renamed

2/19/2002: Managed Care Requirements deleted

5/1/2002: Type of Service and Place of Service deleted

8/19/2002: HCPCS code E0652 description added

9/20/2002: Policy reviewed, Sources updated

8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately

10/17/2005: ICD-9 Diagnosis 990 deleted

7/13/2006: Policy updated

1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions.

11/20/2008: Policy reviewed by MPAC, no changes

12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions

08/12/2010:  Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema."  Policy description revised to add information regarding available pumps. Links added to related medical policies. The first policy statement was revised to add "non-programmable" and the term "elastic" was changed to "compression."  Policy statement regarding multi-chamber programmable lymphedema pumps was changed from not medically necessary to medically necessary under certain circumstances; single compartment programmable pumps are addressed in the same policy statement. Added policy statement to indicate that two-phase multi-chamber lymphedema pumps are investigational for treatment of lymphedema.  FEP verbiage added to the Policy Exceptions section.

09/09/2010: Policy description updated to add information regarding compression pumps for treating truncal areas.  Policy statement unchanged.

09/23/2011: Added the following to the Policy Statement:  Single compartment or multichamber lymphedema pumps are considered investigational in all situations other than those specified above in the first two policy statements.  Deleted outdated References from the Sources section.

02/17/2012: Add the following to the Policy Statement: Pneumatic compression devices prescribed for patients undergoing surgery as a means of prophylaxis to prevent Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) should be included in the surgical facility's claim. This does not meet the criteria for Durable Medical Equipment and may not be billed separately. It is not appropriate for providers to bill the patient for this service.

01/07/2013:  Added "Venous Ulcers" to the policy title. Policy statement revised to add the following investigational statements: 1)The use of lymphedema pumps to treat the trunk or chest in patients with lymphedema limited to the upper and/or lower limbs is considered investigational. 2) The use of lymphedema pumps to treat venous ulcers is considered investigational. Deleted the following policy statement: Two-phase multi-chamber lymphedema pumps are investigational for treatment of lymphedema. Added the following new 2013 CPT code to the Code Reference section:  E0670.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

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