Clinical UM Guideline


Subject: Pneumatic Compression Devices for Lymphedema
Guideline #:  CG-DME-06 Publish Date:    04/25/2018
Status: Revised Last Review Date:    03/22/2018


This document addresses the use of pneumatic compression devices for the treatment of lymphedema. This therapy involves the use of an inflatable garment for various body parts and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Pneumatic compression devices are used in clinics or can be purchased or rented for home use. This document addresses the home use of pneumatic compression devices.

Note: This document addresses devices for the treatment of lymphedema only. Pneumatic devices used in the treatment or prevention of venous thrombosis, venous insufficiency with refractory edema or ulceration, and therapy for musculoskeletal injury are NOT addressed in this document. For information regarding the use of pneumatic devices for other indication please see:

Note: This document does not address pneumatic compression devices with combined cooling or heating functions intended to treat conditions other than lymphedema. For more information regarding such devices, please see:

Note: This document does not address gradient compression stockings/sleeves for post breast surgery upper extremity lymphedema.

Clinical Indications

Medically Necessary:

Single or multi-chamber non-programmable pneumatic compression devices are considered medically necessary when:

Single or multi-chamber programmable (for example, calibrated gradient pressure) pneumatic compression devices are considered medically necessary when criteria above for a non-programmable pneumatic compression device are met and either a or b below are met:

  1. A single or multi-chamber non-programmable pneumatic compression device has been tried for a minimum of 3 months, there is documentation of compliance with treatment with the non-programmable pneumatic compression device, and the records provide objective documentation that lymphedema has progressed; or
  2. There is clear documentation of a condition that prevents the satisfactory treatment of lymphedema with a non-programmable device. Such conditions may include, but are not limited to the following:
    1. Contracture; or
    2. Sensitive skin; or
    3. Significant scarring.

Not Medically Necessary:

Single or multi-chamber programmable or non-programmable pneumatic compression devices are considered not medically necessary when the criteria above have not been met.

Two-stage* multi-chamber programmable pneumatic compression devices are considered not medically necessary.

*Note: Two-stage devices involve an initial programmed compression of the chest and/or trunk, the “preparatory stage,” followed by a second programmed compression of the affected limb(s), the “drainage” stage.

The use of chest, trunk, head, or neck compression garments (appliances) with a pneumatic compression device in the treatment of lymphedema is considered not medically necessary.


The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Single chamber pump and appliances


Pneumatic compressor, non-segmental home model


Non-segmental pneumatic appliance for use with pneumatic compressor, half arm


Non-segmental pneumatic appliance for use with pneumatic compressor, full leg


Non-segmental pneumatic appliance for use with pneumatic compressor, full arm


Non-segmental pneumatic appliance for use with pneumatic compressor, half leg




Multi-chamber pump and appliances


Pneumatic compressor, segmental home model without calibrated gradient pressure


Segmental pneumatic appliance for use with pneumatic compressor, full leg


Segmental pneumatic appliance for use with pneumatic compressor, full arm


Segmental pneumatic appliance for use with pneumatic compressor, half leg




Multi-chamber programmable pump and appliances (one stage or two stage)


Pneumatic compressor, segmental home model with calibrated gradient pressure


Segmental pneumatic appliance for use with pneumatic compressor, trunk


Segmental pneumatic appliance for use with pneumatic compressor, chest


Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk


Segmental gradient pressure pneumatic appliance, full leg


Segmental gradient pressure pneumatic appliance, full arm


Segmental gradient pressure pneumatic appliance, half leg




Other compression garments (appliances) with a pneumatic compression device


Durable medical equipment, miscellaneous [when specified as pneumatic compression garment with a pneumatic compression device]

Note: compression garments with a pneumatic compression device for the treatment of chest, trunk, head or neck lymphedema are considered not medically necessary.



ICD-10 Diagnosis



Malignant neoplasm of breast


Secondary malignant neoplasm of breast


Carcinoma in situ of breast


Neoplasm of uncertain behavior of breast


Neoplasm of unspecified behavior of breast


Lymphedema, not elsewhere classified


Postmastectomy lymphedema syndrome


Other postprocedural complications and disorders of the circulatory system, not elsewhere classified [when specified as lymphedema]


Hereditary lymphedema

Discussion/General Discussion

Lymphedema is characterized by swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid resulting from impairment of the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition due to congenital absence of lymph vessels and nodes, and may be due to Milroy’s Disease. Secondary lymphedema, which is much more common, results from the destruction or damage of formerly functioning lymphatic channels. Examples include radical surgical procedures with removal of regional groups of lymph nodes (for example, after radical mastectomy), post-radiation fibrosis, and spread of malignant tumors to regional lymph nodes with lymphatic obstruction. Treatment for lymphedema may include mechanical measures (for example, compression garments, bandaging, manual massage, pneumatic compression devices), drugs, and in rare cases, surgery.

Pneumatic compression devices are approved under the U.S. Food and Drug Administration's (FDA's) 510(k) process. They are classified as Class II devices, cardiovascular therapeutic devices, and compressible limb sleeves. Pneumatic compression devices, also known as lymphedema pumps, are used to simulate muscle action in the extremities to stimulate lymph and blood circulation with the goal of decreasing edema due to accumulation of lymphatic fluid. These devices involve the use of sleeve or wrap-like garments which contain one or several inflatable air chambers. Attached to the garment is a control unit which controls the flow of compressed air into the air chamber. During treatment the air chambers inflate in a distal to proximal fashion, squeezing the body in such a way as to encourage lymphatic fluid to flow back to the heart. Some devices come with control units that are programmable, allowing variation in the duration and frequency of the inflation cycles, as well as the degree of compression in individual air chambers in the garment. The ability to vary different aspects of this type of treatment has been suggested as a method of optimizing the treatment process, but there is no evidence to demonstrate the superiority of programmable devices compared to non-programmable devices. In a systematic review published in 2012, Oremus et al. reviewed 44 studies evaluating the use of various conservative therapies for the treatment of secondary lymphedema, most of which involved upper limb lymphedema secondary to breast cancer. They reported that the available evidence is of poor quality and that significant heterogeneity made between-study or between-therapy comparisons impossible. They concluded that there is currently no evidence to demonstrate the superiority of any one therapy for lymphedema.

A limited number of small studies have been published. Szuba and colleagues (2002) reported on two small randomized controlled trials (RCTs) (n=23 and 27, respectively). The results of these studies showed that during initial treatment, standard therapy plus pneumatic compression for treatment-naive subjects resulted in significant limb volume reduction compared to standard care alone. However, they found that during the maintenance period, these benefits did not persist in some individuals. In contrast to these findings, earlier small randomized controlled studies by Johansson et al (1998), and Dini and colleagues (1998) found no significant difference between pneumatic pump therapy when compared to either no care or standard care groups.

More recent studies reported similar results. Gurdal and colleagues (2013) reported the results of a RCT involving 30 subjects randomized to receive one of two different combination treatments for lymphedema. Fifteen subjects received manual lymphatic drainage (MLD) and compression bandage combination (Group 1). The remaining 15 subjects were treated with intermittent pneumatic compression (IPC) plus self-lymphatic drainage (SLD) (Group 2). Both groups received treatment for 3 days a week, every other day, for 6 weeks. Arm circumferences were measured before treatment and at 1, 3, and 6 weeks. Quality of life was measured using the EORTC-QLQ and ASES evaluation tools before and after 6 weeks of treatment. Both groups had significant decrease in total arm volume (12.2% decrease in Group 2 and 14.9% decrease in Group 1; p<0.001), but no significant difference was found between the two groups (p=0.582). Similarly, ASES scores were significantly (p=0.001) improved in both groups without any significant difference between the groups. The authors did note that while emotional functioning, fatigue, and pain scores were significantly improved in both groups, measures of global health status, functional and cognitive functioning scores appeared to be improved only in patients of Group 1. A similarly designed RCT was reported by Uzkeser et al. in 2013. In this study, 15 subjects were randomized to receive complex decongestive therapy (CDT) that included skin treatment, MLD, compression bandages, compression garments, and exercise (Group 1). Another group was randomized to receive CDT in addition to intermittent pneumatic compression therapy (Group 2). Both groups were treated 5 times a week for 3 weeks. Significant benefits were reported for both groups, but no differences between groups were noted. Given these recent results, large well-designed randomized controlled trials are warranted to better understand the potential impact of this therapy.

Fife and others (2012) conducted an RCT with 36 subjects randomized to receive treatment with either a standard non-programmable multi-chamber pneumatic compression device (n=18) or a programmable, multi-chamber compression device (n=18). The latter group included both extremity and partial chest/trunk therapy, while the standard group received only upper extremity therapy. Treatment in both groups was 1 hour a day for 12 weeks. The authors report that after 12 weeks the percentage edema volume, calculated as the difference between the volume in mL of the treated arm volume compared to the contralateral arm, was significantly better in the programmable therapy group (-29 ± 44% in the programmable group vs. +16 ± 63% for the non-programmable group;  p=0.018). There were a total of six adverse events reported that were classified as either “possibly” or “definitely” device-related; one in the programmable group and five in the standard group. No statistics were provided for this difference. It should be noted that edema volume is used as the primary outcome metric in this study. Data regarding lymphedema symptoms, quality of life, or functional outcomes are not presented. While this pilot study indicates some potential benefits to the use of programmable devices, the small study population, lack of blinding, and failure to measure clinically relevant outcomes limit the generalizability of this data. Evidence from larger RCTs or other comparative studies is needed to evaluate whether programmable devices should be used first line as opposed to after failure of a non-programmable device.

There are few studies available describing the use of pneumatic compression devices for the treatment of head and neck lymphedema. The only prospective study involved 44 subjects and reported on the usability and treatment-related lymphedema changes following a single treatment (Mayrovitz, 2018). The authors reported a small but statistically significant reduction in composite metrics of the face (82.5 ± 4.3 cm vs 80.9 ± 4.1 cm; p<0.001) and neck (120.4 ± 12.2 cm vs 119.2 ± 12.1 cm; p<0.001), with no adverse events. While these results are promising, additional larger, long-term studies are needed to establish the role of this approach in standard treatment regimens.

Two-Stage Devices

Multi-chamber programmable pneumatic compression devices may also function with two-phases. The first phase, referred to as the “preparatory phase,” compresses the trunk (chest/abdomen). The preparatory phase is designed to prepare the limb for a secondary (drainage) compression phase. The combination of these two phases (preparation plus drainage) has been proposed as a method to further enhance lymph drainage.

The available evidence addressing the clinical use of two-stage multi-chamber programmable pneumatic compression devices is limited. In addition to several case reports published in journals not recognized in the National Library of Medicine’s PubMed database (Cannon, 2009; Hammond, 2009a, 2009b), there are a few case series and a limited number of RCTs available. The Ridner (2008) case series initially included 286 participants who underwent treatment with a two-stage compression device for 2 months. Prior to treatment, and 2 months following the initiation of treatment, the subjects were asked to respond to a survey instrument regarding Quality of Life (QOL) and satisfaction with the device. In addition to methodological flaws such as the use of self-reported data, lack of a control group, no blinding and a significant loss to follow-up (36%), the study does not report health-related outcomes, such as limb volume reduction, skin tension and elasticity, and limb heaviness.

Muluk and colleagues published the results of a prospective case series study involving 196 subjects with lower extremity lymphedema (2013). The majority (181 of 196) of subjects were treated with a two-stage treatment regimen. A total of 88% (n=173) of the subjects experienced a significant reduction in limb volume with 35% reporting a reduction greater than 10%. Mean limb volume reduction was 1,150 mL or 8% (p<0.0001). Clinician assessment indicated that the majority of patients experienced improvement in skin fibrosis (86%, n=168) and function (77%, n=149). However, it is not clear what tools were used to make these assessments.

A randomized controlled, cross-over trial which included 10 subjects with unilateral breast cancer-associated lymphedema of the arm compared treatment with a two-stage device vs. self-administered massage (Wilburn, 2006). The authors reported significant improvement in limb volume, mean subject weight, but no significant differences in SF-26 quality of life scores. There was no comparison to conventional single-stage pump therapy in this very small study with a limited follow-up period of only 4 weeks.

A small RCT of two-stage compression therapy has been published. Ridner and colleagues (2012) studied 42 subjects randomized to receive either upper extremity-only compression treatment (control group; n=21) or extremity plus chest and trunk compression treatment (two-stage therapy) (experimental group; n=21). Control subjects underwent 30 treatments of 36 minutes each. The experimental group received 30 treatments of 1 hour each. The first treatment was supervised in the office, but all subsequent sessions were unsupervised in the home. The authors reported significant improvements with regard to function and anatomical measures in both groups, but no significant differences between groups.

In 2017, Karaca-Mandic and colleagues published the results of a retrospective analysis of administrative claims from 1731 subjects with cancer (n=621) and non-cancer-related (n=1110) lymphedema who were treated with either a segmented non-programmable pneumatic compression device (n=1013) or the Flexitouch device (n=718). Further stratification for the subjects with cancer-related lymphedema resulted in 247 subjects treated with the non-programmable pump and 374 treated with the Flexitouch device. For the non-cancer subjects, there were 766 subjects treated with the non-programmable pump and 344 in the Flexitouch group. Data are presented for the first 12 months of therapy. At baseline, the non-programmable group had a high proportion of obesity, diabetes, hypertension, and renal disease (p<0.001 for all). The Flexitouch group had a significantly higher proportion of breast cancer vs the non-programmable group (76% vs. 43%, p=<0.001). In the cancer group, the Flexitouch group had a higher rate of improvement in cellulitis vs the non-programmable group (79% reduction vs. 53%, p=0.02). The rate of outpatient services was significantly better in the Flexitouch group vs. the non-programmable group (reduction of 1.84 vs. 0.31, p=0.001). The rate of hospitalizations was not significantly different between groups, and use of manual therapy declined a similar amount for each group, with no significant differences. In the non-cancer group, the Flexitouch group had a higher rate of improvement in cellulitis vs the non-programmable group (76% reduction vs. 54%, p=0.003). The use of manual therapy declined at a greater rate in the Flexitouch group vs. the non-programmable group (p=0.04). The rate of outpatient services was significantly better in the Flexitouch group vs. the non-programmable group (reduction of -22.8% vs. -7.8%, p<0.001). The rate of hospitalizations did not change in non-programmable group, whereas it did improve significantly in the Flexitouch group (6/6% to 2/9%, p=0.03). Overall the authors noted that outpatient service use was reduced in both device groups, with greater reductions observed in Flexitouch group. Also, both device groups experienced reductions in manual therapy use. Inpatient hospitalizations were largely stable with reductions observed only in the non-cancer cohort of the Flexitouch group. They conclude that use of the Flexitouch device “was associated with superior lymphedema-related health outcomes and reductions in cellulitis.” 

In summary, the available evidence regarding two-stage devices published in the peer-reviewed medical literature does not demonstrate that the use of two-stage devices improves the net health outcome or is as beneficial as established alternative, such as single-stage (non-programmable or programmable) treatment of lymphedema.

Lymphedema Related to Massive Obesity

There is some low-level evidence that massive obesity may rarely be a cause of massive localized lymphedema (MLL), a condition affecting the pelvic region and lower extremities (Chopra, 2015; Mehrara, 2014). Several case reports and small case series studies have been published characterizing MLL (Fife, 2008, 2014; Green, 2013, 2015a).

In the only report of its kind, Green (2015b) published the results of a case series study involving 51 subjects with Body Mass Index (BMI) greater than 30 kg/m2 and lymphedema with no other potential causes of the condition. All subjects underwent lymphoscintigraphy to assess lower extremity lymphatic function. The authors reported that subjects with abnormal lymphoscintigraphy results had higher BMI vs. subjects with normal results (mean 64.9 kg/m2 vs. 38.8 kg/m2; p<0.0001). Subjects were stratified into two groups. Group 1 subjects were at their maximum BMI (n=33), while group 2 subjects had experienced some weight loss at the time of lymphoscintigraphy (n=18). All subjects in group 1 with a BMI less than 50 kg/m2 (n=20) had normal lymphoscintigraphy results. In the same group, all subjects with a BMI greater than 60 kg/m2 (n=9) had abnormal results. In group 2, subjects with abnormal lymphoscintigraphy results had higher maximum BMI history (p=0.03) as well as higher BMI at the time of the scan (p=0.005) compared to subjects in group 1 with normal results. These results appear to indicate that MLL is directly correlated with higher BMI, specifically BMI over 50 kg/m2.

The treatment of MLL can be a significant challenge due to the large size and location of the lymphedema. The preferred method of treatment is currently surgical excision, especially when ulcers or infections are present. However, there is some anecdotal evidence that such lesions may return, and with greater severity than the initial lesion (Fife, 2014). Additionally, there is some evidence that massive weight loss does not reverse the presence of MLL (Green, 2015a, 2015b). Given the difficulty in treating MLL, conservative therapy of the lower extremities with pneumatic compression therapy may be reasonable. The use of pneumatic compression therapy for MLL related truncal lymphedema has not been demonstrated to provide any significant benefit.

Specialty Society Recommendations

In 2014 the Society for Vascular Surgery published their guidelines for the management of venous leg ulcers (O’Donnell, 2014). With regard to the use of Intermittent Pneumatic Compression, they state the following:

We suggest use of intermittent pneumatic compression when other compression options are not available, cannot be used, or have failed to aid in venous leg ulcer healing after prolonged compression therapy. [GRADE - 2; LEVEL OF EVIDENCE - C]


Peer Reviewed Publications:

  1. Cannon S. Pneumatic compression devices for in-home management of lymphedema: two case reports. Cases J. 2009; 2:6625.
  2. Chopra K, Tadisina KK, Brewer M, et al. Massive localized lymphedema revisited: a quickly rising complication of the obesity epidemic. Ann Plast Surg. 2015; 74(1):126-132.
  3. Dini D, Del Mastro L, Gozza A, et al. The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol. 1998; 9(2):187-190.
  4. Fife C. Massive localized lymphedema, a disease unique to the morbidly obese: a case study. Ostomy Wound Manage. 2014; 60(1):30-35.
  5. Fife CE, Benavides S, Carter MJ. A patient-centered approach to treatment of morbid obesity and lower extremity complications: an overview and case studies. Ostomy Wound Manage. 2008; 54(1):20-2, 24-32.
  6. Fife CE, Davey S, Maus EA, et al. A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home. Support Care Cancer. 2012; 20(12):3279-3286.
  7. Greene AK, Grant FD, Maclellan RA. Obesity-induced lymphedema nonreversible following massive weight loss. Plast Reconstr Surg Glob Open. 2015a; 3(6):e426.
  8. Greene AK, Grant FD, Slavin SA, Maclellan RA. Obesity-induced lymphedema: clinical and lymphoscintigraphic features. Plast Reconstr Surg. 2015b; 135(6):1715-1719.
  9. Greene AK, Maclellan RA. Obesity-induced upper extremity lymphedema. Plast Reconstr Surg Glob Open. 2013; 1(7):e59.
  10. Gurdal SO, Kostanoglu A, Cavdar I, et al. Comparison of intermittent pneumatic compression with manual lymphatic drainage for treatment of breast cancer-related lymphedema. Lymphat Res Biol. 2012; 10(3):129-135.
  11. Hammond T. Reduction of complications and costs associated with Flexitouch therapy for lymphedema. Open Rehabil J. 2009; 2:54-57.
  12. Johansson K, Lie E, Ekdahl C, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998; 31(2):56-64.
  13. Karaca-Mandic P, Hirsch AT, Rockson SG, Ridner SH. A comparison of programmable and non-programmable compression devices for treatment of lymphedema using an administrative health outcomes dataset. Br J Dermatol. 2017; 177(6):1699-1707.
  14. Macdonald JM, Sims N, Mayrovitz HN. Lymphedema, lipedema and the open wound: the role of compression therapy. Surg Clin North Am. 2003; 83(3):639-658.
  15. Mayrovitz HN, Ryan S, Hartman JM. Usability of advanced pneumatic compression to treat cancer-related head and neck lymphedema: a feasibility study. Head Neck. 2018; 40(1):137-143.
  16. Mehrara BJ, Greene AK. Lymphedema and obesity: is there a link? Plast Reconstr Surg. 2014; 134(1):154e-160e.
  17. Muluk SC, Hirsch AT, Taffe EC. Pneumatic compression device treatment of lower extremity lymphedema elicits improved limb volume and patient-reported outcomes. Eur J Vasc Endovasc Surg. 2013; 46(4):480-487.
  18. Oremus M, Dayes I, Walker K, Raina P. Systematic review: conservative treatments for secondary lymphedema. BMC Cancer. 2012; 12:6.
  19. Pappas CJ, O'Donnell TF Jr. Long-term results of compression treatment for lymphedema. J Vasc Surg. 1992; 16(4):555-562.
  20. Ridner SH, McMahon E, Dietrich MS, Hoy S. Home-based lymphedema treatment in patients with cancer-related lymphedema or noncancer-related lymphedema. Oncol Nurs Forum. 2008; 35(4):671-680.
  21. Ridner SH, Murphy B, Deng J, et al. A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema. Breast Cancer Res Treat. 2012; 131(1):147-158.
  22. Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer. 2002; 95(11):2260-2267.
  23. Uzkeser H, Karatay S, Erdemci B, et al. Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial. Breast Cancer. 2015; 22(3):300-307.
  24. Wilburn O, Wilburn P, Rockson SG. A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema. BMC Cancer. 2006; 6:84.
  25. Zanolla R, Monzeglio C, Balzarini A, Martino G. Evaluation of the results of three different methods of postmastectomy lymphedema treatment. J Surg Oncol. 1984; 26(3):210-213.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Health Research and Quality. Technology Assessments: Diagnosis and Treatment of Secondary Lymphedema. May 28, 2010. Available at: Accessed February 5, 2018.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Pneumatic Compression Devices. NCD #280.6. Effective January 14, 2002. Available at: Accessed on February 5, 2018.
  3. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2009 Consensus Document of the International Society of Lymphology. Lymphology. 2009; 42(2):51-60.
  4. O'Donnell TF Jr, Passman MA, Marston WA, et al; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014; 60(2 Suppl):3S-59S.

ACTitouch Adaptive Compression Therapy
LymphFlow Advance
LymphaPress Optimal
NormaTec PCD

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History




  11/15/2018 Added note to Description section clarifying that gradient compression stockings/sleeves for post breast surgery upper extremity lymphedema are not addressed in this document.



Medical Policy & Technology Assessment Committee (MPTAC) review. Added head and neck pneumatic compression to the NMN statement. Updated Description, Discussion and References sections. Updating coding section to include HCPCS E1399.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion and References sections.



MPTAC review. Updated formatting in Clinical Indications section. Updated Reference section.



MPTAC review. Added clarification to medically necessary section regarding the use of multi-chamber programmable pumps. Updated Discussion/General Information and References sections. Removed ICD-9 codes from Coding section.



MPTAC review. No change to clinical indications. Updated References section.



MPTAC review. Added new criteria for programmable pump use. Added note in not medically necessary statement addressing use of two-stage devices. Updated Rationale and References sections.



MPTAC review. Added not medically necessary statement to address the use of pneumatic compression devices for the trunk and chest. Updated Discussion and References sections. Updated Coding section with 01/01/2013 HCPCS changes.



MPTAC review. Deleted position statement addressing venous insufficiency, Updated Discussion, Coding, References, and Index sections.



Updated title to add “for Lymphedema” and added note to Description section to clarify scope of document.



MPTAC review. No change to position statement. Updated Coding and References sections.



MPTAC review. No change to position statement. Updated Discussion and References sections.



MPTAC review. No change to position statement. Added LymphaPress Optimal, NormaTec PCD devices to document. Updated Discussion and References sections.



Updated coding section with 01/01/2009 HCPCS changes.



MPTAC review. Clarified not medically necessary statement. Revised Discussion section.



MPTAC review. Added not medically necessary statement for single or multi-compartment programmable or non-programmable pneumatic compression devices when medically necessary criteria have not been met; updated Reference section.



MPTAC review. No change to position; updated reference section.



Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).



MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number




Anthem, Inc.





Anthem BCBS


Memo 115

Lymphedema Pumps


Anthem BCBS



Pneumatic Compression Devices


WellPoint Health Networks, Inc.



Lymphedema Pumps