Rule 5160-10-14 | DMEPOS: compression garments.
(A) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2024).
(B) Payment may be made only for compression garments generating a pressure of at least eighteen millimeters of mercury (mm Hg).
(C) For a gradient compression garment, the provider specifies at least one clinical indication such as but not limited to the conditions identified in the following list:
(1) Elephantiasis;
(2) Lymphedema;
(3) Milroy's disease;
(4) Orthostatic hypotension;
(5) Post-thrombotic syndrome;
(6) Stasis dermatitis;
(7) Stasis ulcers;
(8) Symptomatic chronic venous insufficiency (characterized by, for example, pain, swelling, ulcers, or severe varicose veins);
(9) Symptomatic venous insufficiency associated with pregnancy; or
(10) Thrombophlebitis.
(D) Payment for an anti-embolism compression garment may be limited to three months, because such garments are generally used for short-term treatment after surgery.
(E) Payment for a post-burn compression garment cannot be made if no burn injury has occurred.
(F) It is understood that because of the nature of certain applications, authorization for payment may be granted after an item has been dispensed.
Last updated July 2, 2024 at 10:45 AM
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