| Durable Medical Equipment Section - Multi-Chamber Programmable
Pneumatic Compression Pumps
Topic: Multi-Chamber Programmable
Pneumatic Compression Pumps
|
Date of Origin: 11/2009 |
Section: Durable Medical Equipment
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Policy No: 78 |
| Effective Date: 06/01/2011 |
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DESCRIPTION
Multi-chamber programmable pneumatic compression pumps
may be used to lessen the accumulation of fluids in
the arms, legs or trunk, to treat chronic venous insufficiency,
or to prevent blood clot formation in immobile patients. Similar
in action to the way a blood pressure cuff inflates
and deflates, these devices provide air compression
to segmented sleeves that are wrapped around the limbs
or trunk. These multi-chambered sleeves can be
individually adjusted to allow different pressures
(gradient pressure) in each segment.
NOTE: This policy addresses only multi-chamber programmable pumps
described by HCPCS code E0652. This policy does not address
single- or multi-chamber non-programmable pumps,
which are considered a standard of care for the treatment
of lymphedema, prevention of venous thromboembolism in
high risk patients, and chronic venous insufficiency.
POLICY/CRITERIA
Multi-chamber programmable pneumatic compression pumps
(HCPCS code E0652) are considered not medically
necessary because these programmable pumps
are more costly, but have not been shown to be superior
to either single compartment or multi-chamber non-programmable
pneumatic compression pumps.
POSITION STATEMENT
Although generally more costly, multi-chamber programmable
pneumatic compression pumps have not been shown to
be superior to single compartment or multi-chamber
non-programmable pneumatic compression pumps for the
treatment of any condition.
Effectiveness
Randomized Controlled trials
There is no reliable evidence from well-designed,
well-executed randomized controlled trials comparing
the effectiveness of multi-chamber programmable pneumatic
compression pumps with either single compartment or
multi-chamber non-programmable pneumatic compression
pumps.
Case series, retrospective reviews, and other non-randomized
comparative studies
Data on the effectiveness of pneumatic compression
devices remains limited. The evidence consists
primarily of small non-randomized trials for a variety
of single and multi-chamber pumps. While these studies
contribute to the body of knowledge by providing direction
for future research, evidence from these studies is
limited and unreliable due to inherent design flaws
including but not limited to the following:
- Non-random allocation of treatment which may introduce
selection or response bias. [1-3]
- Lack of blinding may bias treatment effect estimates.
[1-3]
- Lack of appropriate comparison groups which do
not permit conclusions on the efficacy of multi-chamber
programmable pumps compared to other available pumps.
[1,3,4]
- Variable pump protocols limit effective analysis
across studies because it is difficult to determine
whether a treatment effect is related to the pump
type or protocol used. [1]
- Small study populations which limit the ability
to rule out the role of chance as an explanation
of findings. [1,2,4]
- Variable patient baseline characteristics such
as severity of conditions (e.g. lymphedema) which
may bias treatment effect estimates. [1]
Safety
Concerns about damage to remaining
intact lymphatics caused by too high pump pressures
have been reported; however, these concerns are not
well quantified in the literature. [1]
Technology Assessments, Clinical Practice
Guidelines, and Position Statements
A 2010 Agency for Healthcare Research and Quality.
(AHRQ )Technology Assessment on lymphedema pumps concluded
that there “was no evidence from which to determine
whether one type of [intermittent pneumatic compression]
device or sleeve were more effective than others were
across the continuum.” [5]
REFERENCES
- TEC Assessment 1998. "Special Report: Comparative
Efficacy of Different Types of Pneumatic Compression
Pumps for the Treatment of Lymphedema." BlueCross
BlueShield Association Technology Evaluation Center,
Vol. 13, Tab 2.
- Mayrovitz HN. Interface pressures produced by two
different types of lymphedema therapy devices. Phys
Ther. 2007 Oct;87(10):1379-88. PMID: 17712034
- 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 Jul;35(4):671-80. PMID:
18591171
- Wilburn O, Wilburn P, Rockson SG. A pilot, prospective
evaluation of a novel alternative for maintenance
therapy of breast cancer-associated lymphedema [ISRCTN76522412]. BMC
Cancer. 2006;6:84. PMID: 16571129
- Agency for Healthcare Research and Quality. (AHRQ
)Technology Assessment, Diagnosis and Treatment of
Secondary Lymphedema. 2010. [cited 03/24/2011];
Available from: http://www.cms.gov/determinationprocess/downloads/id66aTA.pdf
- BlueCross BlueShield Association Medical Policy
Reference Manual "Pneumatic Compression Pumps
for Treatment of Lymphedema." Policy No. 1.01.18
CROSS REFERENCES
None
| Codes |
Number |
Description |
| CPT |
None |
|
| HCPCS |
E0652 |
Pneumatic compressor, segmental
home model with calibrated gradient pressure |
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