Single-compartment or multichamber nonprogrammable lymphedema pumps applied to the limb 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.
Single-compartment or multichamber programmable lymphedema pumps applied to the limb may be considered medically necessary for the treatment of lymphedema when:
1. The individual is otherwise eligible for nonprogrammable pumps; and
2. There is documentation that the individual has unique characteristics (eg, significant scarring) that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable lymphedema pumps.
Single-compartment or multichamber lymphedema pumps applied to the limb are considered investigational in all situations other than those specified above in the first 2 policy statements.
The use of lymphedema pumps to treat the trunk or chest in patients with lymphedema with or without involvement of the upper and/or lower limbs is considered investigational.
The use of lymphedema pumps applied to the head and neck to treat lymphedema is considered investigational.
The use of pneumatic compression pumps to treat venous ulcers is considered investigational.
