Medical Policy Update

Medical Policy: Compression Pumps for Treatment of Lymphedema and Venous Ulcers

1. Single-compartment or multichamber nonprogrammable pneumatic compression pumps applied to the limbs may be considered medically necessary for the treatment of lymphedema that has failed to respond to conservative measures, such as elevation of the limb and use of compression garments.
2. Single-compartment or multichamber programmable pneumatic compression pumps applied to the limbs may be considered medically necessary for the treatment of lymphedema when:
   1. The individual is otherwise eligible for nonprogrammable pneumatic pumps; AND
   2. There is documentation that the individual has unique characteristics (e.g., significant scarring, recent surgery) that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable compression pumps; OR
   3. The individual has had an inadequate response to an initial course of treatment with a nonprogrammable pneumatic compression pump applied to the limbs (see Policy Guidelines).
3. Single-compartment or multichamber nonprogrammable pneumatic compression pumps applied to the chest or trunk in addition to the limbs may be considered medically necessary for the treatment of lymphedema that has failed to adequately respond to both conservative measures and nonprogrammable pneumatic compression to the limbs only.
4. Single-compartment or multichamber programmable pneumatic compression pumps applied to the chest or trunk in addition to the limbs may be considered medically necessary for the treatment of lymphedema when:
   1. The individual is otherwise eligible for nonprogrammable pneumatic pumps applied to the chest or trunk in addition to the limbs; AND
   2. There is documentation that the individual has unique characteristics (e.g., significant scarring, recent surgery) that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable compression pumps; OR
   3. The individual has had an inadequate response to an initial course of treatment with a nonprogrammable pneumatic compression pump applied to the chest or trunk in addition to the limbs (see Policy Guidelines).
5. Single-compartment or multichamber compression pumps are considered investigational in all situations other than those specified above, including when applied to the head or neck.
6. Programmable, wearable non‑pneumatic compression pumps (e.g., Koya Dayspring) applied to the limbs may be considered medically necessary when:
   1. The individual is otherwise eligible for a programmable pneumatic compression pump; AND
   2. There is documentation that the individual has lifestyle considerations or mobility requirements where treatment compliance with a traditional programmable pneumatic compression system is expected to be insufficient.
7. Programmable, wearable non‑pneumatic compression pumps are considered investigational in all other situations not specified above.
8. The use of pneumatic or non‑pneumatic compression pumps to treat venous ulcers is considered investigational.

Policy Guidelines

Medically necessary positions for treatment of lymphedema at body sites other than the limbs are based on clinical input. Additional details from clinical input are detailed in the Appendix. Individuals who fail to respond to an initial trial of a nonprogrammable pump may benefit from programmable pumps with pulsatile features that can be tailored to address individual lymphatic flow dysfunction patterns. Clinical input supports the use of non‑pneumatic compression pumps on the basis of the evidence and clinical experience, emphasizing the importance of compliance with treatment. Clinical input was mixed on the use of compression pumps for the treatment of head and neck lymphedema. Ongoing evidence generation in head and neck cancer populations is expected to elucidate clinical benefit.

Effective Date: 7/1/2026
Preauthorization Required: Yes

Policy

Postsurgical home use of limb compression devices for VTE prophylaxis may be considered medically necessary in individuals with a contraindication to pharmacologic agents (see Policy Guidelines), in the following situations:

• After major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip fracture surgery); OR
• After major nonorthopedic surgery or other orthopedic procedures in individuals who are at moderate or high risk of VTE (see Policy Guidelines).

Postsurgical home use of limb compression devices for VTE prophylaxis for periods longer than 30 days post‑surgery is considered investigational.
Postsurgical home use of limb compression devices for venous thromboembolism (VTE) prophylaxis is considered investigational in all other situations, including but not limited to:

• After major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip fracture surgery) in individuals without a contraindication for anticoagulation; OR
• After major nonorthopedic surgery or other orthopedic procedures in individuals without a contraindication for anticoagulation who are at moderate or high risk of VTE (see Policy Guidelines).

Medical Policy: Ophthalmologic Imaging Techniques for Glaucoma and Anterior Eye Segment Evaluation

Effective Date: 7/1/2026
Preauthorization Required: Yes

Posterior Segment Imaging Techniques for Glaucoma

1. Analysis of the optic nerve and retinal nerve fiber layer for the diagnosis and evaluation of individuals with glaucoma or glaucoma suspects may be considered medically necessary when performed using any of the following technologies:
   1. Scanning laser ophthalmoscopy
   2. Scanning laser polarimetry
   3. Optical coherence tomography (OCT) of the posterior segment
2. The following techniques are considered investigational for the diagnosis or follow‑up of individuals with glaucoma:
   1. Measurement of ocular blood flow
   2. Pulsatile ocular blood flow
   3. Blood flow velocity

Codes: 92133, 0198T

Optical Coherence Tomography of the Anterior Eye Segment

1. Scanning computerized ophthalmic imaging, including optical coherence tomography (OCT) of the anterior eye segment, is considered investigational.

Code: 92132