Non-segmental pneumatic appliance for use with pneumatic compressor, half leg Non-segmental pneumatic appliance for use with pneumatic compressor, full leg Pneumatic compressor, segmental home model with calibrated gradient pressure Pneumatic compressor, segmental home model without calibrated gradient pressure Pneumatic compressor, non-segmental home model HCPCS codes covered if selection criteria are met:Ĭompression burn garment, foot to knee length, custom fabricatedĬompression burn garment, foot to thigh length, custom fabricated Codes requiring a 7th character are represented by "+": Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code If the benefit plans covers graded compression stockings or non-elastic binders, please see list of medical conditions in Section I to meet medical necessity criteria.įootnote4**** Only pressure gradient support stockings are considered medically necessary for this indication inflatable compression garments have no proven value for this indication. Please check benefit plan descriptions for details. Note: Aetna's standard benefit plans do not cover graded compression stockings or non-elastic binders because they are considered an outpatient consumable or disposable supply.
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