Compression support garments These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for compression support garments.

Coverage

Compression garments are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

1. Must be part of a treatment plan for venous insufficiencies, or to decrease contractures related to burns, which could result in a physical functional loss. 2. Conditions for which compression support garments (ready or custom made) may be indicated include, but are not limited to, the following: A. Varicose veins B. Venous ulcers (also referred to as stasis ulcers) C. Venous insufficiency D. Stasis dermatitis E. Peripheral edema F. Varicosities of pregnancy G. Orthostatic hypotension H. Thrombophlebitis I. Lymphedema 3. Ready-made or custom-made compression support garments, such as JOBST, Medi Strumpf, Sigvaris, ReidSleeve and CircAid compressions devices. 4. Legacy compression garments are covered and indications for use are: lymphostatic low-flow, high- protein edema or radiation fibrosis. 5. Four garments per affected limb (leg or arm) are covered per 12 month period, regardless of brand name (unless member has burns or post-mastectomy lymphedema – then see #6). When both legs and arms are affected, 4 pair are covered per 12 months. When only one leg or arm is affected, 2 pair – 4 individual stockings – are covered per 12 month period. The 12 month period is calculated using a “rolling year” (a period of 12 months that begins and ends on a set day). The 12 month period for garment limits begins on the date of the first (or most recent) purchase and extends for 12 months. 6. Compression garments in excess of the limits in #5 are covered when both of the following conditions are met: A. The additional compression garments are ordered by a physician; and B. The garments are used: i. for burn patients to decrease contractures, or ii. to treat post-mastectomy lymphedemas. 7. Miscellaneous items, such as garters, zippers or adhesive lotions are covered when deemed essential to the use of the garment. 8. Stocking liners, when used for ulcer care, are covered and are limited to six per involved area per 12 month period (liners are sold three to a box). 9. Compression / lymphedema bandages are covered for intractable lymphedema of the extremities. Garment quantity limits do not apply to these bandages. Bandages & compression garments may be covered at the same time if medically necessary.

Indications that are not covered

1. T.E.D.™ hose or anti-embolism elastic support hose. 2. Items which are primarily for comfort, convenience or recreation are excluded from coverage. 3. Garments when used to decrease scarring for cosmetic purposes. 4. Compression garments for the abdomen, chest, genitals, trunk or neck, are considered experimental and investigational for any indication other than burns or post-mastectomy lymphedema. There is a lack of peer-reviewed published literature evaluating the clinical utility of compression garments for these anatomical sites. Examples of these types of garments include vests, such as the Tribute® vest or torso garment (Solaris, West Allis, WI). (Please refer to the Breast Prosthesis coverage policy for coverage of mastectomy bras. See Related Content at right for link.)

Definitions

Anti-Embolism Stockings (e.g., T.E.D.™ hose) usually provide 8–18mmHg of compression and can be purchased over the counter without a prescription. Anti-embolism stockings are designed specifically for non-ambulatory (bed bound) patients. These are intended for short term wear during hospitalization to help prevent blood from pooling in the legs, which can lead to blood clots. They provide a lower level of compression than graduated/gradient compression stockings.

Compression support garments (sometimes referred to as lymphedema garments) decrease swelling by increasing the blood return to the heart. They are designed to promote and restore normal fluid circulation in patients with swelling due to lymphedema. They include arm sleeve, glove/gauntlet, stocking, foot cap, and pantyhose styles. They may be elastic or non-elastic. Non-elastic compression garments utilize a non-elastic textile that is fastened by adjustable hooks and loops to provide compression. They can be worn during the day or night. Both custom-made and prefabricated garments are available.

Compression garments are also used for severe burns to decrease scarring which can cause contractures, therefore preventing physical functional loss. They are tightly fitted garments and can be purchased off the shelf or custom made.

Compression / lymphedema bandages are minimally elastic (short-stretch) bandages which provide adequate tissue pressure to prevent reaccumulation of lymphedema.

Edema is swelling that is caused by excess tissue fluid that has not yet returned to the circulatory system. This can occur as a normal response to injury (such as a sprained ankle), or due to circulatory system problems such as chronic venous insufficiency or congestive heart failure. Swelling usually occurs in the lower areas of the body (legs and feet).

Graduated (also called Gradient or Graded) Compression Stockings are specialized hosiery that provide graduated pressure on the lower legs and feet to help prevent thrombosis (blood clots). They use stronger elastics to create significant pressure (usually 30-70 mm Hg) on the legs, ankles and feet. Graduated compression stockings should be tightest at the ankles and gradually become less constrictive toward the knees and thighs. They are available by prescription only and are used to treat venous and lymphatic disorders in ambulatory patients. They are used for all stages of chronic venous insufficiency, including varicose veins, edema, stasis skin changes and venous (sometimes called stasis) ulcers. They may also be used in preventing and treating post-thrombotic syndrome.

Long-stretch bandages contain elastic fibers that enable stretching to approximately 140% to 300% of their original length. Ace™ bandages are an example. These bandages stretch as edema increases. They also provide little resistance to calf-muscle contraction. Therefore, they have low working pressure, do not promote calf-muscle pump, and provide poor edema containment.

Lymphedema is swelling caused by excess protein-rich lymph trapped within the tissues. Lymphedema is caused by damage to the lymphatic system (such as removal of lymph nodes due to breast cancer) and the swelling occurs near the affected area.

Phlebitis is inflammation of a vein.

Short-stretch bandages are woven with cotton fibers and stretch to about 30% to 60%. Examples include the Rosidal K® and Comprilan® bandages typically used in lymphedema management. A short-stretch system used in venous ulcer management is the Coban™ 2 layer compression system. Multilayered short-stretch bandaging systems cause high working pressure, as they do not allow the calf muscles to bulge outward when they contract, generating inward pressure which forces venous return. Multilayered short-stretch bandages also act as a semi-rigid force to prevent expansion of edema. They offer excellent containment of all forms of edema.

Thrombophlebitis is an inflamed vein, with or without a small blood clot inside the vein. Thrombophlebitis is commonly just called phlebitis. Thrombophlebitis in a varicose vein develops as a tender hard knot in the vein. There is often erythema (redness) and bleeding may occur as the reaction extends through the vein wall. It is common with venous stasis ulcers. Codes If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Surgical Stockings and Bandages Code Description A4490 Surgical stockings above knee length, each A4495 Surgical stockings thigh length, each A4500 Surgical stockings below knee length, each A4510 Surgical stockings full length, each A6448 Light compression bandage, elastic, knitted/woven, width less than 3 in, per yard A6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in and less than 5 in, per yard A6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 in, per yard A6451 Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 ft lbs at 50% maximum stretch, width greater than or equal to 3 in and less than 5 in, per yard A6452 High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 ft lbs at 50% maximum stretch, width greater than or equal to 3 in and less than 5 in, per yard

Burn Garments Code Description A6501 Compression burn garment, bodysuit (head to foot), custom fabricated A6502 Compression burn garment, chin strap, custom fabricated A6503 Compression burn garment, facial hood, custom fabricated A6504 Compression burn garment, glove to wrist, custom fabricated A6505 Compression burn garment, glove to elbow, custom fabricated A6506 Compression burn garment, glove to axilla, custom fabricated A6507 Compression burn garment, foot to knee length, custom fabricated A6508 Compression burn garment, foot to thigh length, custom fabricated A6509 Compression burn garment, upper trunk to waist, including arm openings (vest), custom fabricated A6510 Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated A6511 Compression burn garment, lower trunk including leg openings (panty), custom fabricated A6512 Compression burn garment, not otherwise classified A6513 Compression burn mask, face and/or neck, plastic or equal, custom fabricated

Gradient Compression Stockings/ Wraps Code Description A6530 Gradient compression stocking, below knee, 18 - 30 mm Hg, each A6531 Gradient compression stocking, below knee, 30 - 40 mm Hg, each A6532 Gradient compression stocking, below knee, 40 - 50 mm Hg, each A6533 Gradient compression stocking, thigh length, 18 - 30 mm Hg, each A6534 Gradient compression stocking, thigh length, 30 - 40 mm Hg, each A6535 Gradient compression stocking, thigh length, 40 - 50 mm Hg, each A6536 Gradient compression stocking, full-length/chap style, 18 - 30 mm Hg, each A6537 Gradient compression stocking, full-length/chap style, 30 - 40 mm Hg, each A6538 Gradient compression stocking, full-length/chap style, 40 - 50 mm Hg, each A6539 Gradient compression stocking, waist length, 18 - 30 mm Hg, each A6540 Gradient compression stocking, waist length, 30 - 40 mm Hg, each A6541 Gradient compression stocking, waist length, 40 - 50 mm Hg, each A6544 Gradient compression stocking, garter belt A6545 Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each A6549 Gradient compression stocking/sleeve, not otherwise specified CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

Approved Medical Director Committee 01/01/94; Revised 10/20/03, 9/13/06, 4/10/09, 11/22/13, 11/3/16; Annual Review 9/13/06, 8/1/07, 7/1/08; 4/10/09, 6/16/10, 06/2011, 10/2011, 8/2012, 10/2013, 11/2013, 11/2014, 11/2015, 10/2016, 10/2017, 10/2018, 10/2019, 10/2020

References 1. Armstrong, D. G., & Meyr, A. J. Compression therapy for the treatment of chronic venous insufficiency. In:UpToDate , Mills Sr., J. L., & Eidt, J. F. (Ed). UpToDate, Waltham, MA. Accessed on October 9, 2020 2. Engrav, L. H., Heimbach, D. M., Rivara, F. P., Moore, M. L., Wang, J., Carrougher, G. J., Gibran, N. S. (2010). 12-Year within-wound study of the effectiveness of custom pressure garment therapy. Burns, 36, 975-983. 3. Gloviczki, P., Comerota, A. J., Dalsing, M. C., Eklof, B. G., Gillespie, D. L., Glovisczki, M. L., … Wakefield, T. W. (2011). The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF). Journal of Vascular Surgery, 53(16S), 2S-48S.. 4. International Society of Lymphology (2016). The diagnosis and treatment of peripheral lymphedema: 2016 consensus document. Lymphology, 49, 170-184. 5. International Society of Lymphology (2020). The diagnosis and treatment of peripheral lymphedema: 2020 consensus document. Lymphology 53 (2020) 3-19, 6. Lim, C,, Davies A (2014) Graduated Compression Stockings, Canadian Medical Association Journal, 186 (10) : E391- E398. 7. Mehrara, B. Clinical staging and conservative management of peripheral lymphedema. In: UpToDate, Eidt, J. F., Berman, R. S., & Mills Sr., J. L. (Ed), UpToDate, Waltham, MA. Accessed on October 9, 2020 8. NICE (2013). Varicose veins: diagnosis and management (clinical guideline). Retrievedfrom nice.org.uk/. 9. O’Donnell, T. F., Passman, M. A., Marston, W. A., Ennis, W. J., Dalsing, M., Kistner, R. L., Gloviczki, P. (2014). Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF): Management of venous leg ulcers. Journal of Vascular Surgery, 60, 3S-59S. 10. O’Meara, S., Cullum, N., Nelson, E. A., & Dumville, J. C. (2012). Compression for venous leg ulcers. Cochrane Database of Systematic Reviews, 11, 1-192.. 11. Wound, Ostomy, and Continence Nurses Society. (2017). Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide , Mt. Laurel, NJ