Compression Garments

For DOS on or before December 31, 2009

Types of Compression Garments

The following types of compression garments are defined below:

• Ready-to-wear compression garments.
• Custom-made compression garments.
• Non-elastic binders.
• Over-the-counter garments.

Ready-to-Wear Gradient Compression Garments

Ready-to-wear gradient compression garments (e.g., Jobst, SigVarus, Venes) are defined as pre-made and having a gradient pressure of 18 mmHg or more. A signed and dated physician's prescription is required to identify both the member's diagnosis and the specific garment needed, as well as to prescribe the amount of compression required. Circumferential and length measurements are required for fitting. Ready-to-wear garments may be equipped with zippers and/or reinforced areas, such as heels.

Allowable HCPCS procedure codes for ready-to-wear gradient compression garments include the following: A6530-A6541, S8421, S8424, S8427, and S8428.

Reimbursement for ready-to-wear gradient compression garments includes the following:

• Consideration for small to extra-large and short to tall ready-to-wear sizes.
• The addition of liners and zippers in ready-to-wear sizes when liners and/or zippers are medically necessary.

Custom-Made Gradient Compression Garments

Custom-made gradient compression garments are defined as garments that are uniquely sized and/or shaped and custom made to fit the exact dimensions of the affected extremity (circumferential measurements every 1.5 to two inches) and provide accurate and consistent gradient compression to manage the member's symptoms. A signed and dated physician's prescription is required to identify both the member's diagnosis and the specific garment needed, as well as to prescribe the amount of compression required. Circumferential and length measurements are required for fitting. Garments with zippers and/or reinforced areas alone are not considered as meeting the definition of a custom-made garment.

The following are examples of custom-made gradient compression garments:

• A garment requiring a unique fit due to the size and/or shape of the member's limb (circumferential measurements every 1.5 to two inches).
• A garment requiring the application of unique materials (e.g., Elvarex). Zippers or reinforced areas, such as heels, are not considered to be unique materials.

Allowable HCPCS procedure codes for custom-made gradient compression garments include the following: A6542, S8420, S8422, S8425, and S8426.

Reimbursement for custom-made gradient compression garments includes the following:

• Consideration for small to extra-large and short to tall ready-to-wear sizes.
• The addition of liners and zippers in ready-to-wear sizes when liners and/or zippers are medically necessary.

Non-Elastic Binders

Non-elastic binders (e.g., CircAid, LegAssist, Reid Sleeve) are defined as garments that provide continuous compression using adjustable hook and loop or buckle straps. A signed and dated physician's prescription is required to identify both the member's diagnosis and the specific garment needed, as well as to prescribe the amount of compression required. Circumferential and length measurements are required for fitting.

HCPCS procedure code S8429 is allowed for non-elastic binder compression garments.

Reimbursement for non-elastic binder compression garments includes the following:

• Consideration for small to extra-large and short to tall ready-to-wear sizes.
• The addition of liners and zippers in ready-to-wear sizes when liners and/or zippers are medically necessary.

Over-the-Counter Garments

Wisconsin Medicaid does not reimburse providers for compression garments purchased over-the-counter with or without a prescription and having a pressure of less than 18 mmHg (e.g., elastic stockings, surgical leggings, anti-embolism stockings T.E.D. hose, or pressure leotards).

Medical Necessity Requirements

Medical necessity is defined in DHS 101.03(96m), Wis. Admin. Code. Individually fitted prescription gradient compression garments (stockings, sleeves, gauntlets, gloves) and non-elastic binders are generally considered medically necessary and do not require PA for members who have any of the following medical conditions:

• Treatment of any of the following documented complications of chronic venous insufficiency:
  • Varicose veins (except spider veins).
  • Stasis dermatitis (venous eczema).
  • Venous ulcers (stasis ulcers).
  • Venous edema.
  • Lipodermatosclerosis.
• Prevention of thrombosis in immobilized persons (e.g., immobilization due to surgery, trauma, debilitation).
• Post thrombotic syndrome (post phlebitic syndrome).
• Chronic lymphedema.
• Edema following surgery, fracture, burns, or other trauma.
• Post sclerotherapy.
• Clinically significant postural hypotension with documented changes in systolic/diastolic pressures.
• Severe edema in pregnancy.
• Edema secondary to paraplegia, quadriplegia, etc.

Additional Requirements for Non-Elastic Binders

In addition to the medical necessity requirements for compression garments, non-elastic binders (e.g., LegAssist, CircAid) may be additionally medically necessary for members who meet the following criteria:

• The member's continuing requirement for bandaging 23 hours per day after completion of intensive lymphedema treatment, or
• The member's requirement for nighttime compression,

and

• The documented inability of the member or an available caregiver to perform bandaging independently.

Contraindications

The use of compression garments for members with severe peripheral arterial disease or septic phlebitis is generally contraindicated. Gradient compression garments should be used with caution in the case of decreased or absent sensation in the extremity, allergy to the compression material, moderate peripheral arterial disease, or infection in the extremity. Reimbursement for compression garments for any of these medical conditions requires submission of a PA request if one of these contraindications is present.

Life Expectancy

For all covered compression garments, life expectancy is established at three garments per twelve months. Providers may issue new garments only when a new garment is medically necessary. It is medically necessary to replace a garment when the garment's integrity cannot be restored or repaired. PA is not required until greater than three garments per procedure code per twelve months is medically necessary.

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