OAR 410-122-0658: Gradient Compression Stockings/Sleeves

(1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division may cover gradient compression stockings/sleeves for the following indications when the client meets the conditions of coverage in OAR 410-122-0080 and when all the following guidelines and criteria are met: (A) Ulceration due to chronic venous insufficiency; (B) Varicose veins with ulcer or inflammation; (C) Phlebitis/thrombophlebitis; (D) Deep vein thrombosis (DVT) prophylaxis during pregnancy and postpartum or immobilization due to surgery, trauma, or debilitation; (E) Funded lymphedema conditions even in the absence of ulcers or other complications; and (F) Edema following a covered surgery, fracture, burns, or other trauma; (b) A gradient compression stocking may be covered when it is used to secure a primary dressing over an open venous stasis ulcer that is currently being treated by a practitioner and requires medically necessary debridement and when the gradient stocking delivers compression less than 50 mmHg; (c) Two (2) gradient compression stockings/sleeves per affected limb may be provided at dispensing (the second one is for use while the first one is being laundered); (d) Replacement stockings/sleeves are limited to two (2) per affected limb every six (6) months. Requests for quantities that exceed this amount require detailed medical documentation (e.g., change in size, unusual drainage, wear that renders them ineffective); (e) Custom-made gradient compression stockings/sleeves require prior authorization with documentation that supports that the treating practitioner has considered ready-made gradient compression stockings/sleeves and the reason why they will not meet the medical needs of the client. (f) The following services are not covered: (A) Antiembolism stockings (A4490-A4510); (B) Garter belts (A6544); (C) Stockings/sleeves for the following conditions: (i) Solely for the purpose of air travel; (ii) Treatment of non-funded lymphedema conditions; (iii) Venous insufficiency without stasis ulcers; (D) Support hose (pantyhose). (2) Gradient compression garments, related supplies and accessories are covered for the treatment of lymphedema and in accordance with the Prioritized List of Health Services Lymphedema Guideline Note. (a) A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months; (b) A quantity of two (2) nighttime garments per body area are allowed once every two (2) years; (c) Replacements needed in cases of loss, theft, or irreparable damage may be covered by the Division in accordance with OAR 410-122-0184; (d) Lymphedema compression treatment items include the following: (A) Standard and custom daytime gradient compression garments; (B) Nighttime gradient compression garments; (C) Gradient compression wraps with adjustable straps; (D) Compression bandaging systems; (E) Accessories such as zippers, liners/linings, padding or fillers that are necessary for the effective use of a gradient compression garment or wrap; (F) Refer to Table 122-0658 for a complete list of HCPCS codes; (G) DMEPOS providers shall refer to the product classification list on the Medicare Pricing, Data Analysis and Coding (PDAC) contractor website for coding verification and HCPCS codes used to identify specific durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). (3) Documentation Requirements: Medical records that support the conditions of coverage are met, as specified in this rule, shall be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request. (4) Table 122-0658 [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]