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Inflatable compression garments or individually fitted prescription graded compression stockings provide gentle pressure to either arms or legs, to avoid swelling and other problems.  Often, gradient compression stockings are prescribed for prevention of post-operative thrombosis.

A prosthetic sheath may be used alone, placed directly on an amputated limb, or under a prosthethic sock. These garments wick away moisture and help prevent skin breakdown.

• third degree burns
• deep second degree burns
• areas of skin which have received a skin graft.

Burn anti-pressure garments for treatment of any other disorders are not covered.

Gradient (or graded) compression stocking may be considered medically necessary when prescribed by a physician for treatment of lymphedema, venous stasis or any of the following:

• Varicose veins (except spider veins)
• Chronic venous insufficiency
• Venous stasis disease
• Venous valvular insufficiency
• Venous insufficiency
• Post thrombotic syndrome
• Venous ulcer (stasis ulcer), including ANY ONE of the following:
  • Edema
  • Venous
  • Lymph
  • Post traumatic
  • Post surgical
  • Lipedema
• Angiodysplasia
• Prevention of thrombosis post-operatively
• Post sclerotherapy
• Thrombosis prevention
• Venous eczema
• Lipodermatosclerosis

The degree of pressure required must be at least 25mm Hg.

Four (4) pair of compression stockings are covered for a 12-month period of time.

One post-mastectomy camisole may be covered immediately following mastectomy.

Two post-mastectomy bras and one breast prosthesis are covered following mastectomy. Thereafter, the two bras may be replaced once a year and the prosthesis replaced once every three to five years.

Sport bras are not covered.

Seven (7) prosthetic sheaths and seven (7) pair of prosthetic socks are covered per year.

None

Reimbursement for the fitting of garments is not covered.

These items are major medical supplies, not Durable Medical Equipment, and are subject to the deductible as specified in the Member's individual contract.

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

2/19/2002: Managed Care Requirements deleted, table added

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

3/12/2003: Code Reference section updated

11/5/2003: Code Reference section updated, ICD-9 diagnosis code 454.0, 454.1, 454.2, 454.8, 454.9, 457.0, 459.10, 459.11, 459.12, 459.13, 459.19, 459.2, 459.30, 459.31, 459.32, 459.33, 459.39, 459.89, 941.49, 942.20, 942.25, 942.43, 942.53, 942.54, 943.30, 944.38, 944.48, 944.58 added

5/27/2004: Code Reference section updated, HCPCS L8195 added, HCPCS L8100, L8110, L8120, L8130, L8140, L8150, L8160, L8170, L8180, L8190, L8200, L8210, L8220, L8230, L8239 description revised

3/27/2006: Coding updated. HCPCS 2006 revisions added to policy

3/28/2006: Policy reviewed, no changes

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

12/15/2009: Code Section updated with 2010 CPT/HCPCS revisions

4/22/2010:  Policy statement revised to change "gradient pressure aids" to "gradient compression stockings" and included medical indications for the compression stockings.  The number of pair of compression stockings was changed from seven (7) pair per year to four (4) pair for a 12-month period of time. Removed outdated source and added Centers for Medicare and Medicaid Services in the Sources section.  Added the following verbiage in the Code Reference section: "*Some covered procedure codes have multiple descriptions.  Coverage will only be made for covered codes when used for services outlined within the policy statement section."  Added ICD- 9 Diagnosis codes 451.0 - 451.2 and 747.64 to the Covered Codes Table; and revised the description of ICD-9 diagnosis code 757.0.

11/29/2012:  Policy statement revised to state that one post-mastectomy camisole may be covered immediately following mastectomy. Added S8460 to the Covered Codes table.

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

Covered Codes