Compression Garments denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flexitouch pneumatic compression pump. Pneumatic compression devices may be used at home as part of self-care. In a one-year trial of Flexitouch advanced pneumatic compression devices in 74 different patients with phlebolymphedema or lymphedema secondary to chronic venous insufficiency, researchers found that while an improvement in quality of life was not demonstrated at 12 weeks, there were steady and sustained benefits at one year. A researcher reports that a panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Flexitouch Plus pneumatic compression device (PCD) and the associated garment. A pneumatic compressor appliance has been requested by the patient’s providers to manage his head and neck lymphedema. Craniofacial lymphedema treatment represents unique challenges not addressed by extremity lymphedema therapies. Complete decongestive therapy, consisting of manual lymphatic drainage (MLD), tissue compression bandages, remedial exercises, and skin care are standard approaches to address the condition. However, these interventions may not be effective in nearly 40% of patients, as they rely on patient self-administration.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage Koya Dayspring® Active system (including smart controller and full arm garment). Standard therapy for extremity lymphedema is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. Advanced pneumatic compression devices (APCDs) mimic manual massage therapy and are an accepted and proven form of outpatient therapy for the treatment of extremity lymphedema. Over the past decade, APCDs have shown beneficial clinical results and reductions in adverse events such as infection and hospitalization. Researchers reported a 79% decrease in cellulitis infection after 12 months of APCD use and a 29% reduction in outpatient lymphedema visits.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for water cooling and compression device for the knee fluid circulating cold pad with pump. This patient was being treated for unilateral primary osteoarthritis of the left knee. She purchased a cooling and compression device for her knee after a planned total knee arthroplasty. One study notes that, “Although cryotherapy is indicated to reduce pain in the postoperative period of knee arthroplasty, studies have many methodological biases and the meta-analysis performed could not confirm the effects; therefore, more primary studies are needed to better understand the effects.” This is further corroborated by another study which reports that, “Immediate and early postoperative management following TKA (total knee arthroplasty) remains challenging.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Compression Garments, then check the rights and deadlines that apply to your plan.