Ordering Process

Lymphedema – Insurance criteria including Medicare for ordering a pneumatic compression device (E0651) for treating Lymphedema

How to initiate an order: Download, complete, sign, and fax completed and signed copy of VasoCARE’s Prescription, copy of the patient’s face sheet, and progress notes to 866.455-5150. VasoCARE will verify the patient’s primary insurance and a VasoCARE representative will contact you if additional documentation is required in completing the process.

Patient’s medical records must include the following to meet criteria for a pneumatic compression device:

Documented diagnosis of lymphedema must be noted in the records, the cause of lymphedema, any history of surgical, cancer, traumatic episodes, or other causes that interrupted normal lymphatic drainage of the extremity, or if the lymphedema is congenital.

Date of onset of swelling

Objective findings must list one of the following skin changes:

Note: If progress notes do not document one or more skin changes, then detailed measurements are required to show the progression of the lymphedema.

□ Patient has completed at least 4 weeks of failed conservative therapies or reason (s) why the patient was unable to implement:

Physician oversight of treatment plan is demonstrated by physician’s notes.

Note: Medicare denies coverage when all of the questions on the Certificate of Medical Necessity (CMN) are answered “no”. VasoCARE offers self-pay options for patients that do not meet the above criteria.

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Upgrading a lymphedema patient to an E0652 pneumatic compression device with calibration requires additional information:

Patient has undergone a trial with a basic pump. A “basic” pump is defined as a pump delivering non-calibrated pressures with no appliances to treat the trunk or chest.

A basic pump must first be used to determine if it meets the patient’s medical need.

□ Documentation must demonstrate the basic pump’s level of in-effectiveness in treating patient’s swelling, fibrosis, and level of pain

□ Patient’s inability to tolerate pressure prior to E0652 prescription.

Documentation of a basic pump trial should include:

Unique characteristics that prevented satisfactory treatment with basic pump should include:

□ Patient demonstrates significant fibrosis, scarring, and/or proximal swelling

□ Patient complained of pain or intolerance to the pump’s pressures

Justifications for why a more advanced pneumatic compression pump with calibration (E0652) is medically necessary

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Venous Stasis Ulcers - Insurance criteria including Medicare for ordering a pneumatic compression device (E0651) for patients suffering with Venous Stasis Ulcers.

How to initiate an order: Fax completed and signed copy of VasoCARE’s Prescription, copy of the patient’s face sheet, and progress notes to 866.455-5150. VasoCARE will verify the patient’s primary insurance and a VasoCARE representative will contact you if additional documentation is required in completing the process.

Patient’s medical records must include the following to meet criteria for a pneumatic compression device:

Documented diagnosis of chronic venous insufficiency with non-healing venous ulcer (s) must be noted in the records. Documentation must include 6 months of continuous treatment of the non-healing ulcer.

Objective findings that establish the severity of the condition. Medical records must include:

Record of failed conservative therapies documented for a minimum of 6 months:

Physician oversight of treatment plan over the last 6 months is noted in the patient’s notes.

Medical records show unhealed ulcer(s) remain despite 6 months of conservative therapies.

Note: Medicare denies coverage when all questions on the Certificate of Medical Necessity (CMN) are answered “no”. VasoCARE offers self-pay options for patients that do not meet the above criteria.

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Upgrading a Venous Stasis Ulcer patient to an E0652 pneumatic compression device with calibration requires additional information:

□ Patient has undergone a trial of a basic pump. A “basic” pump is defined as a non-calibrated pump.

A basic pump must first be used to determine if it meets the patient’s medical need.

□ Documentation must demonstrate the basic pump’s level of in-effectiveness in treating patient’s swelling, fibrosis, and level of pain

□ Patient’s inability to tolerate pressure prior to E0652 prescription.

Documentation of a basic pump trial should include:

Documentation showing unique characteristics that prevented satisfactory treatment with basic pump:

□ Patient demonstrated significant fibrosis, scarring, and/or proximal swelling

Justifications for why a more advanced pneumatic compression pump with calibration (E0652) is medically necessary

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device

Download Prescription for Pneumatic Compression Device