Postsurgical Home Use of Limb Compression Devices for ... · prophylaxis be provided rather than no thromboprophylaxis.1 The guidelines further recommend the use of pharmacologic

MEDICAL POLICY

POLICY TITLE POSTSURGICAL HOME USE OF LIMB COMPRESSION DEVICES FOR VENOUS

THROMBOEMBOLISM PROPHYLAXIS (FORMERLY POSTSURGICAL

OUTPATIENT USE OF LIMB COMPRESSION DEVICES FOR VENOUS

THROMBOEMBOLISM PROPHYLAXIS)

POLICY NUMBER MP- 6.053

Page 1

Original Issue Date (Created): 2/1/2014

Most Recent Review Date (Revised): 7/26/2016

Effective Date: 1/1/2017

I. POLICY

Postsurgical, home use of limb compression devices for venous thromboembolism (VTE)

prophylaxis may be considered medically necessary in patients with a contraindication to

pharmacologic agents (see Policy Guidelines), in the following situations:

• Following major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip

fracture surgery); OR

• Following major nonorthopedic surgery or other orthopedic procedures in patients who

are at moderate or high risk of VTE (see Policy Guidelines)

Postsurgical, home use of limb compression devices for VTE prophylaxis is considered

investigational in all other situations, including but not limited to:

• Following major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip

fracture surgery) in patients without a contraindication for anticoagulation; OR

• Following major nonorthopedic surgery or other orthopedic procedures in patients in

patients without a contraindication for anticoagulation who are at moderate or high risk

of VTE (see Policy Guidelines)

Postsurgical, home use of limb compression devices for VTE prophylaxis for periods longer than

30 days postsurgery is not medically necessary.

POLICY GUIDELINES This section reviews guidance on contraindications to use of anticoagulants, determining risk for

bleeding, determining risk for venous thromboembolism (VTE), and duration of treatment

postoperatively.

Contraindications to Anticoagulants

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND

RATIONALE DEFINITIONS BENEFIT VARIATIONS

DISCLAIMER CODING INFORMATION REFERENCES

POLICY HISTORY

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The main contraindication to anticoagulants is a high risk of bleeding. However, there is not an

absolute threshold at which anticoagulants cannot be used. Rather there is a risk/benefit

continuum that takes into account the benefit of treatment as well as the risks of bleeding. There

may also be intolerance to specific agents, although this is uncommon. Intolerance may occur as

a result of allergic reactions or intolerable adverse effects. Finally, when heparin preparations are

used, there can be the development of serum antibodies and heparin-induced thrombocytosis that

precludes further use of heparin products.

Guidance on Determining High Risk for Bleeding American College of Chest Physicians (ACCP) guidelines on prevention of venous

thromboembolism (VTE) in orthopedic surgery patients list the following general risk factors for

bleeding (Falck-Ytter et al, 2012):

Previous major bleeding (and previous bleeding risk similar to current risk)

Severe renal failure

Concomitant antiplatelet agent

Surgical factors: history of or difficult-to-control surgical bleeding during the current

operative procedure, extensive surgical dissection, and revision surgery

The guidelines note, however, that “specific thresholds for using mechanical compression

devices or no prophylaxis instead of anticoagulant thromboprophylaxis have not been

established.”

A clinical guideline from the American Academy of Orthopaedic Surgeons (2011) states:

“Patients undergoing elective hip or knee arthroplasty are at risk for bleeding and bleeding-

associated complications. In the absence of reliable evidence, it is the opinion of this work group

that patients be assessed for known bleeding disorders like hemophilia and for the presence of

active liver disease which further increase the risk for bleeding and bleeding-associated

complications. (Grade of Recommendation: Consensus) Current evidence is not clear about

whether factors other than the presence of a known bleeding disorder or active liver disease

increase the chance of bleeding in these patients and, therefore, the work group is unable to

recommend for or against using them to assess a patient's risk of bleeding. (Grade of

Recommendation: Inconclusive)”

Guidance on Duration of Use In patients with contraindications to pharmacologic prophylaxis who are undergoing major

orthopedic surgery (total hip arthroplasty, total knee arthroplasty, hip fracture surgery), ACCP

guidelines are consistent with use of intermittent limb compression devices for 10 to 14 days

after surgery (Falck-Ytter et al, 2012). The ACCP suggestion on extended prophylaxis (up to 35

days) was a weak recommendation that did not mention limb compression devices as an option.

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In the ACCP guideline on VTE prophylaxis in patients undergoing nonorthopedic surgery, the

standard duration or “limited duration” of prophylaxis were not defined. However, “extended

duration” pharmacologic prophylaxis was defined as 4 weeks, which was recommended only for

patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer and not

otherwise at high risk for major bleeding complications.

Guidance on Determining Risk Level for Nonorthopedic Surgery The ACCP guidelines on prevention of VTE in nonorthopedic surgery patients included the

following discussion of risk levels (Gould et al, 2012):

“In patients undergoing general and abdominal-pelvic surgery, the risk of VTE varies depending

on both patient-specific and procedure-specific factors. Examples of relatively low-risk

procedures include laparoscopic cholecystectomy, appendectomy, transurethral prostatectomy,

inguinal herniorrhaphy, and unilateral or bilateral mastectomy. Open-abdominal and open-pelvic

procedures are associated with a higher risk of VTE. VTE risk appears to be highest for patients

undergoing abdominal or pelvic surgery for cancer….

Patient-specific factors also determine the risk of VTE, as demonstrated in several relatively

large studies of VTE in mixed surgical populations. Independent risk factors in these studies

include age > 60 years, prior VTE, and cancer; age ≥>60 years, prior VTE, anesthesia ≥ 2 h, and

bed rest ≥ 4 days; older age, male sex, longer length of hospital stay, and higher Charlson

comorbidity score; and sepsis, pregnancy or postpartum state, central venous access, malignancy,

prior VTE, and inpatient hospital stay > 2 days. In another study, most of the moderate to strong

independent risk factors for VTE were surgical complications, including urinary tract infection,

acute renal insufficiency, postoperative transfusion, perioperative myocardial infarction, and

pneumonia.”

The American College of Obstetricians and Gynecologists proposed the following risk

classification for VTE in patients undergoing major gynecological surgery

(http://guidelines.gov/content.aspx?id=11429):

“Low: Surgery lasting less than 30 minutes in patients younger than 40 years with no

additional risk factors.

Moderate: Surgery lasting less than 30 minutes in patients with additional risk factors;

surgery lasting less than 30 minutes in patients age 40 to 60 years with no additional risk

factors; major surgery in patients younger than 40 years with no additional risk factors.

High: Surgery lasting less than 30 minutes in patients older than 60 years or with

additional risk factors; major surgery in patients older than 40 years or with additional

risk factors. Highest: Major surgery in patients older than 60 years plus prior venous

thromboembolism, cancer, or molecular hypercoagulable state.”

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Cross-reference:

MP- 6.013 Pneumatic Compression Devices for Treatment of Lymphedema and Chronic

Venous Insufficiency

II. PRODUCT VARIATIONS TOP

This policy is applicable to all programs and products administered by Capital BlueCross unless

otherwise indicated below.

BlueJourney HMO* BlueJourney PPO* FEP PPO**

* Refer to Durable Medical Equipment Regional Carrier (DME MAC A) Region JA Noridian

Healthcare Solutions, LLC Local Coverage Determination (LCD) L33829 Pneumatic

Compression Devices.

**Refer to FEP Medical Policy Manual MP-1.01.28 Post-Surgical Outpatient Use of Limb

Compression Devices for Venous Thromboembolism Prophylaxis. The FEP Medical Policy

manual can be found at: www.fepblue.org

III. DESCRIPTION/BACKGROUND TOP

Patients undergoing major surgery are at increased risk of developing deep vein thrombosis

(DVT) and pulmonary embolism (PE), together known as VTE. Patients who are having major

orthopedic surgery (defined here as total hip arthroplasty [THA], total knee arthroplasty [TKA]

and hip fracture surgery [HFS]) are at particularly high risk. Risk of DVT is increased due to

venous stasis of the lower limbs as a consequence of immobility during and after surgery. In

addition, direct venous wall damage associated with the surgical procedure itself may occur.

DVTs are frequently asymptomatic and generally resolve when mobility is restored. However,

some episodes of acute DVT can be associated with substantial morbidity and mortality. The

most serious adverse consequence of an acute DVT is a PE, which can be fatal; this occurs when

the DVT detaches and migrates to the lungs. In addition, DVT may produce long-term vascular

damage that leads to chronic venous insufficiency. Without thromboprophylaxis, the incidence

of venographically detected DVT is approximately 42% to 57% after total hip replacement, and

the risk of PE is approximately 1% to 28%.4 Other surgical patients may also be at increased risk

of VTE during and after hospitalization. For example, it is estimated that rates of VTE without

prophylaxis after gynecologic surgery is about 15% to 40%.5

http://www.fepblue.org/

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Thus, antithrombotic prophylaxis is recommended for patients undergoing major orthopedic

surgery and other surgical patients at increased risk of VTE. For patients undergoing major

orthopedic surgery, clinical practice guidelines published in 2012 by the American College of

Chest Physicians (ACCP) recommend that one of several pharmacologic agents or mechanical

prophylaxis be provided rather than no thromboprophylaxis.1 The guidelines further recommend

the use of pharmacologic prophylaxis during hospitalization, whether or not patients are using a

limb compression device.

A minimum of 10 to 14 days of prophylaxis is recommended, a portion of which can be post

discharge outpatient use.

The ACCP guidelines noted that compliance is a major issue with limb compression devices

used for thromboprophylaxis and recommend that, if this prophylactic option is selected, use

should be limited to portable, battery-operated devices. Moreover, it is recommended that

devices be used for 18 hours per day. A 2009 nonrandomized study found that there was better

compliance with a portable battery-operated limb compression device compared to a nonmobile

device when used by patients in the hospital following hip or knee replacement surgery.6

ACCP also issued guidelines on VTE prophylaxis in nonorthopedic surgery patients.3 For

patients undergoing general or abdominal-pelvic surgery who have a risk of VTE of 3% or

higher, ACCP recommends prophylaxis with pharmacologic agents or intermittent pneumatic

compression rather than no prophylaxis. For patients at low risk for VTE (1.5%), the guidelines

suggest mechanical prophylaxis. Unlike the guidelines on major orthopedic surgery, which

recommend a minimum of 10 to 14 days of VTE prophylaxis, the guideline on nonorthopedic

surgery patients does not include a general timeframe for prophylaxis. They do, however, define

“extended duration” pharmacologic prophylaxis as lasting 4 weeks; the latter is recommended

only for patients at high risk for VTE, undergoing abdominal or pelvic surgery for cancer who

are not otherwise at high risk for major bleeding complications.

National clinical guidelines have not specifically recommended use of limb compression devices

in the outpatient setting. However, especially with the availability of portable, battery-operated

devices, there is interest in use of outpatient limb compression devices for DVT following

discharge from the hospital for major orthopedic and nonorthopedic surgery.

Regulatory Status

Various pneumatic and peristaltic limb compression devices, with indications including

prevention of DVT, have been cleared for marketing by FDA through the 510(k) process.

Portable devices that have been cleared by FDA include:

Venowave™ VW5 (Venowave Inc., Stouffville, Ontario, Canada): The device is a peristaltic

pump that is strapped to the leg below the knee. It is powered using a single NiMH AA

battery.

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ActiveCare+SFT® System (Medical Compression Systems Ltd, or Akiva, Israel): The device

applies sequential pneumatic compression to the lower limb; it has the option of being

battery-operated. Foot compression is achieved with use of a single-celled foot sleeve. Calf

and thigh compression requires use of a 3-celled cuff sleeve.

Restep® DVT System (Stortford Medical LLC, West Windsor, NJ): This is a lightweight

device that utilizes single chamber pressure cuffs attached to the patient’s lower legs.

Kendall SCD™ 700 Sequential Compression System (Covidien, Mansfield, MA): This

pneumatic compression device can be used in the clinic or at home. It has a 2-pronged plug

and is not battery-operated.

IV. RATIONALE TOP

Updated literature reviews has been conducted regularly, most recently through January 27,

2016. The key published literature is summarized below.

Patients With Moderate-to-High Postsurgical Risk of VTE and No Contraindication to

Prophylaxis Using Pharmaceutical Agents The section focuses on evidence that postdischarge use of limb compression device in addition to

pharmaceutical agents provides an incremental benefit to the net health outcome compared with

pharmaceutical agents alone. The ideal study to address this issue is a superiority randomized

controlled trial (RCT) comparing venous thromboembolism (VTE) prophylaxis with

pharmaceutical agents plus limb compression devices versus pharmaceutical agents alone. No

RCTs with this study design were identified in patients who were discharged after major

orthopedic surgery or other types of major surgery. There are, however, RCTs and meta-analyses

of RCTs comparing medication plus compression devices with medication alone in surgical

patients in hospital. These studies address whether the use of limb compression devices added to

pharmacologic therapy improves VTE prophylaxis in the hospital setting, but may not permit

inference to the postdischarge home setting. Meta-analyses of RCTs are described next:

A 2015 meta-analysis by O’Connell et al included 9 RCTs (total N=3347 patients) comparing

IPC, with or without pharmacologic therapy, to pharmacologic agent alone in orthopedic and

neurologic surgical patients.7 Six studies included patients undergoing major orthopedic surgery.

In a pooled analysis of all 9 studies, significantly fewer patients in the IPC group (38/1680

[2.3%]) were diagnosed with DVT than in the control group (89/1667 [5.3%]) (pooled risk ratio

[RR], 0.49; 95% confidence interval [CI], 0.25 to 0.9660%). A pooled analysis of 8 studies did

not find a significant difference in the rate of PE in the IPC and control groups; however, the

total number of events was low (5 [0.6%] in the IPC group vs 7 [0.9%] in the control group) and

5 studies had 0 PE events (pooled RR=0.71; 95% CI, 0.22 to 2.242%).

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In 2014, Zareba et al published a meta-analysis of RCTs comparing combined compression and

pharmacologic prophylaxis with either intervention alone for postsurgical VTE prevention.8

Twenty-five studies met the inclusion criteria: 13 on orthopedic surgery, 7 on abdominal surgery,

3 on neurosurgery, and 1 on cardiac surgery and the population in the remaining study was not

reported. Eleven RCTs (total N=4866 patients) compared pharmacologic prophylaxis plus

compression to pharmacologic prophylaxis alone. IPC was used in 5 studies and graduated

compression stockings were used in the other 6. A pooled analysis of 10 studies found that the

risk of DVT with pharmacologic prophylaxis plus compression was significantly lower than with

pharmacologic prophylaxis alone (5.1% vs 10.4%; RR=0.51; 95% CI; 0.36 to 0.73). In addition,

there was a significant between-group difference in the risk of PE (9 studies; RR=0.43; 95% CI,

0.27 to 0.66). The authors noted that the PE analysis was heavily weighted by 1 large (N=2786

patients) study of patients undergoing cardiac surgery which provided 69 of 89 total PE events.

Four studies reported on symptomatic DVT. A pooled analysis did not find a significant

difference between groups in risk of symptomatic DVT (4 studies; pooled RR=0.39; 95% CI,

0.05 to 2.90).

Sobieraj et al 2013 included RCTs comparing pharmacologic and mechanical prophylaxis versus

either alone in patients undergoing major orthopedic surgery.9 Six trials (total N=961 patients)

were identified, 5 of which compared combination prophylaxis pharmacologic prophylaxis

alone. Mechanical prophylaxis included IPCs, venous foot pumps, and graduated compression

stockings. A pooled analysis of 4 RCTs found a significantly lower risk of DVT with

combination prophylaxis than with pharmacologic prophylaxis alone (RR=0.48; 95% CI, 0.32 to

0.72). In other pooled analyses, there were not significant differences between groups in risk of

PE (2 studies), proximal DVT (3 studies) or distal DVT (2 studies).

A 2012 meta-analysis by Kakkos et al focused on patients undergoing hip and knee replacement.

10 Six RCTs (total N=1399 patients) were included; 4 of them compared pharmacologic plus

mechanical prophylaxis with pharmacologic prophylaxis alone. Three studies included both hip

and knee replacement patients and the fourth included only hip replacement patients. A pooled

analysis of 3 trials on total knee replacement found a significantly lower rate of DVT in the

combined prophylaxis group compared with the pharmacologic prophylaxis only group (3.7% vs

18.7%; RR=0.27; 95% CI, 0.08 to 0.89). Similarly, there was a significantly lower risk of DVT

with combined prophylaxis when findings of 4 studies on hip replacement were pooled (0.9% vs

9.7%; RR=0.17; 95% CI, 0.06 to 0.46.

Section Summary

Findings of the meta-analyses suggest that in-hospital addition of limb compression devices to

pharmacologic management improves VTE prophylaxis, especially for prevention of DVTs.

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Findings on risk of PE are more limited because, perhaps, analyses are underpowered due to the

small number of PE events. However, it is difficult to draw conclusions about the efficacy of

specific devices in specific patient populations due to heterogeneity of studies included in the

meta-analyses. RCTs varied in terms of patient populations (eg orthopedic surgery,

nonorthopedic surgery, medical patients), compression devices (IPCs, foot pumps, sequential

compression devices), co-interventions (eg compression stockings), duration of followup and

outcomes reported. The meta-analyses reported on risk of DVT, but 3 of 4 did not distinguish

between symptomatic DVT, which is more clinically relevant, and asymptomatic (imaging-

detected) DVT.

However, the available evidence does not address the question of interest to this review; whether

there is incremental benefit in the post discharge setting of adding limb compression devices to

pharmacological prophylaxis. There are important characteristics of the post discharge setting

which preclude making interferences from the inpatient setting. Patient characteristics vary,

because discharged patients tend to be healthier than those in hospital. Characteristics of home

use also vary (e.g., consistency, duration, and errors in use). RCTs evaluating the addition of

limb compression devices to pharmacologic management postdischarge in the home setting are

needed to draw conclusions about the incremental benefit of this technology on VTE

prophylaxis.

Patients With Moderate-to-High Postsurgical Risk of VTE and a Contraindication to

Prophylaxis Using Pharmaceutical Agents

This section addresses whether postdischarge limb compression device use in moderate to high

risk patients with a contraindication to pharmacologic prophylaxis improves the net health

outcome compared with no postdischarge VTE prophylaxis. The ideal study design is an RCT

comparing limb compression devices and no prophylaxis after hospital discharge. However,

there may be ethical and practical barriers to conducting such as study, especially in higher-risk

patients. Alternatively, a network meta-analysis could indirectly compare outcomes of limb

compression device use versus no VTE prophylaxis. No RCTs or network meta-analysis of

postdischarge use in patients with contraindication pharmacologic prophylaxis were identified.

There is, however, a meta-analysis of RCTs comparing IPC use with placebo in hospital. The

meta-analysis was published in 2013 by Ho et al.11 It included RCTs comparing IPC to no

prophylaxis or another type of prophylaxis in hospitalized surgical and nonsurgical patients. As

with the meta-analyses reviewed above, there was heterogeneity of participants and

interventions. Studies using a no prophylaxis control group may have been conducted in lower-

risk patients and, in higher-risk patients, some studies also included pharmacologic prophylaxis

in both groups. A pooled analysis of 40 RCTs found a significantly lower rate of DVT with IPCs

(7.3%) versus placebo (16.7%) (RR=0.43; 95% CI, 0.36 to 0.52).

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Similarly, a pooled analysis of 26 trials found a significantly lower rate of PE with IPCs (1.2%)

than placebo (2.8%) (RR=0.48; 95% CI, 0.33 to 0.69). Results of the Ho et al meta-analysis

suggest that IPCs can be beneficial for VTE prophylaxis in patients with a contraindication to

medication.

To make inferences about the benefit of limb compression devices postdischarge, the feasibility

of home use should be considered. An unblinded RCT by Sobieraj-Teague et al (2012) compared

use of a portable battery-operated IPC device to usual care alone in patients undergoing cranial

or spinal neurosurgery.12 All patients were also prescribed graduated compression stockings and

20% to 25% used anticoagulants. Patients were evaluated at 9 days postsurgery and those

discharged sooner could use an IPC at home (median duration of hospitalization, 4 days).

Patients who used the IPC post discharge received home visits at least daily to optimize

compliance. Three (4%) of 75 patients in the IPC group and 14 (19%) of 75 patients in the usual

care group developed VTE; the difference between groups was statistically significant (p=0.008).

Among evaluable patients in the IPC group, 23.3% were continuous users, 53.4% were

intermittent users, and 23.3% discontinued use (this includes both inpatient and outpatient use).

The mean duration of IPC use was 6.6 days. Findings suggest that in home use of IPCs is

feasible with adequate post discharge planning and support.

Section Summary: The meta-analysis by Ho et al supports the conclusion that the use of limb compression devices

is superior to placebo for VTE prevention in hospitalized patients. Notably both DVT and PE

were significantly lower with the use of limb compression. A limitation of the Ho meta-analysis

is that there is not stratification by patient risk level nor was pharmacologic prophylaxis absent in

all cases. Nonetheless, the inference is supported that, in patients with a contraindication to

pharmaceutical prophylaxis, post discharge use of limb compression devices is superior for VTE

prophylaxis to no prophylaxis.

The study by Sobieraj-Teague, although limited by the number of patients and evaluating in only

1 approach to patient support in the home (i.e. daily visits by care provider), is consistent with

the feasibility of post discharge home use of limb compression devices. In the U.S. health care

system, appropriate post discharge planning and transition is recognized as critical to reducing

readmissions.13,14 When appropriate post discharge planning and support is in place, the use of

limb compression devices in the home in moderate-to-high risk patients with a contraindication

to pharmacologic prophylaxis is likely to improve VTE prevention.

Ongoing and Unpublished Clinical Trials

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A search of ClinicalTrials.gov in March 2016 did not identify any ongoing or unpublished trials

that would likely influence this review.

Summary of Evidence In patients with moderate to high postsurgical risk of VTE and no contraindication to

pharmaceutical prophylaxis, there are no randomized controlled trials which assess whether there

is incremental benefit to home use of a limb compression device in addition to pharmaceutical

agents. Relevant outcomes are overall survival, symptoms, morbid events and treatment-related

morbidity. Four meta-analyses of RCTs compared medication plus IPC vs medication alone in

surgical patients in hospital. These studies do not permit inference to the post discharge home

setting. Results of the meta-analyses suggest that in-hospital addition of limb compression

devices to pharmacologic management improves DVT prophylaxis. Limitations are: not

distinguishing between asymptomatic and symptomatic DVT; sparse data on PE; and results

generally not stratified by patient risk or specific intervention. Moreover, there are important

characteristics of the post discharge setting that differ from hospital use. Discharged patients tend

to be healthier than those in hospital. Factors such as consistency, duration, and errors in use

differ in the home. The evidence is insufficient to determine the effects of the technology on

health outcomes.

In patients with a contraindication to pharmacologic prophylaxis and moderate to high risk of

VTE, a meta-analysis of inpatients and a study of use in the home setting support inferences on

whether use of post discharge limb compression improves the net health outcome compared to

no prophylaxis. Outcomes of interest are overall survival, symptoms, morbid events and

treatment related morbidity. The meta-analysis showed significantly lower DVT (40 RCTs) and

PE (26 RCTs) with limb compression.

Despite limitations related to stratification of patient risk and pharmacologic prophylaxis, the

meta-analysis shows that limb compression is superior to no prophylaxis. A study of post

discharge use of limb compression with home visits showed that home use is feasible. With post

discharge planning and support, home use of limb compression devices in moderate to high risk

patients who have contraindication to pharmacologic prophylaxis is likely to improve VTE

prevention. The evidence is sufficient to determine qualitatively that the technology results in a

meaningful improvement in the net health outcome.

Practice Guidelines and Position Statements

American College of Chest Physicians In 2012, the American College of Chest Physicians (ACCP) published updated evidence-based

guidelines on prevention of VTE in patients undergoing orthopedic and nonorthopedic surgery.

ACCP recommendations on use of limb compression devices in orthopedic surgical patients

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1:

“2.1.1 In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty

(TKA), we recommend use of one of the following for a minimum of 10 to 14 days rather

than no antithrombotic prophylaxis: low-molecular-weight heparin (LMWH),

fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin

(LDUH), adjusted-dose vitamin K antagonist (VKA), aspirin (all Grade 1B) , or an

intermittent pneumatic compression device (IPCD) (Grade 1C).”

“2.1.2 In patients undergoing hip fracture surgery (HFS), we recommend use of one of

the following rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days:

LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all Grade 1B), or an IPCD

(Grade 1C).”

“2.5. In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis

with an antithrombotic agent and an IPCD during the hospital stay (Grade 2C).

“2.6. In patients undergoing major orthopedic surgery and increased risk of bleeding, we

suggest using an IPCD or no prophylaxis rather than pharmacologic treatment (Grade

2C).”

For all above recommendations related to pneumatic compression pumps, ACCP

recommended only portable, battery-powered devices be used and stated that efforts

should be made to ensure devices are worn for 18 hours a day. Guideline authors noted

that compliance is the biggest challenge with use of pneumatic compression devices.

ACCP recommendations on use of limb compression devices in nonorthopedic general and

abdominal-pelvic surgical patients, stratified by patient risk of VTE and risk of bleeding include

2:

Very low risk patients (<0.5%): “[W]e recommend that no specific pharmacologic (Grade

1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation.”

Low risk for VTE (≈1.5%): “[W]e suggest mechanical prophylaxis, preferably with

intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C).”

Moderate risk for VTE (≈3%) and not at high risk of bleeding: “[W]e suggest low-

molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated h

heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no

prophylaxis.”

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Moderate risk for VTE (≈3%) and high risk for major bleeding complications or in whom

bleeding consequences would be particularly severe: “We suggest mechanical

prophylaxis, preferably with IPC, over no prophylaxis (Grade 2C).”

High risk for VTE (≈6.0%) and not at high risk of bleeding: “[W]e recommend

pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin

(Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical

prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C).”

High risk for VTE (≈6.0%) and high risk for major bleeding complications or in whom

bleeding consequences would be particularly severe: “[W]e suggest use of mechanical

prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding

diminishes and pharmacologic prophylaxis may be initiated (Grade 2C).”

High risk for VTE, both LMWH and unfractionated heparin contraindicated or

unavailable and not at high risk for major bleeding complications: “[W]e suggest low-

dose aspirin (Grade 2C), fondaparinux (Grade 2C), or mechanical prophylaxis, preferably

with IPC (Grade 2C), over no prophylaxis.”

High risk for VTE, undergoing abdominal or pelvic surgery for cancer and not otherwise

at high risk for major bleeding complications: “[W]e recommend extended-duration,

postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration

prophylaxis (Grade 1B).”

Note that a standard duration of prophylaxis was not defined. An “extended-duration”

prophylaxis was defined as lasting 4 weeks.

American Academy of Orthopaedic Surgeons In 2011, the American Academy of Orthopaedic Surgeons published an updated guideline on

prevention of VTE in patients undergoing elective hip and knee arthroplasty.15 The guideline

included the following recommendations relevant to this evidence review:

“- The work group suggests the use of pharmacologic agents and/or mechanical compressive

devices for the prevention of venous thromboembolism in patients undergoing elective hip or

knee arthroplasty, and who are not at elevated risk beyond that of the surgery itself for venous

thromboembolism or bleeding. (Grade of Recommendation: Moderate)

“- Current evidence is unclear about which prophylactic strategy (or strategies) is/are optimal or

suboptimal. Therefore, the work group is unable to recommend for or against specific

prophylactics in these patients. (Grade of Recommendation: Inconclusive)

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“- In the absence of reliable evidence about how long to employ these prophylactic strategies, it

is the opinion of this work group that patients and physicians discuss the duration of prophylaxis.

(Grade of Recommendation: Consensus)

“- In the absence of reliable evidence, it is the opinion of this work group that patients

undergoing elective hip or knee arthroplasty, and who have also had a previous venous

thromboembolism, receive pharmacologic prophylaxis and mechanical compressive devices.

(Grade of Recommendation: Consensus)

“- In the absence of reliable evidence, it is the opinion of this work group that patients

undergoing elective hip or knee arthroplasty, and who also have a known bleeding disorder (eg,

hemophilia) and/or active liver disease, use mechanical compressive devices for preventing

venous thromboembolism. (Grade of Recommendation: Consensus)”

American College of Obstetricians and Gynecologists In 2007, the American College of Obstetricians and Gynecologists published a practice bulletin

on prevention of DVT and PE after gynecologic surgery.5 As with ACCP recommendations

described above, prophylaxis recommendations varied by patient risk level. For patients at

moderate and high risk of DVT, intermittent pneumatic compression was one of the

recommended options for DVT prophylaxis. For patients at highest risk (ie, >60 years plus prior

VTE, cancer, or molecular hypocoagulable state), IPC or graduated compression stockings plus

LDUH or LMWH were recommended as prophylactic options. For all but the highest risk

patients, the practice bulletin stated that, when IPC devices were used, “the devices should be

used continuously until ambulation and discontinued only at the time of hospital discharge.” For

the highest risk patients, the document stated that continuing prophylaxis for 2 to 4 weeks after

discharge should be considered.

American Orthopaedic Foot and Ankle Society In 2013, the American Orthopaedic Foot and Ankle Society published a position statement on

VTE prophylaxis after foot and ankle surgery. It stated that: “There is currently insufficient data

for the American Orthopaedic Foot & Ankle Society (AOFAS) to recommend for or against

routine VTE prophylaxis for patients undergoing foot and ankle surgery. Further research in this

field is necessary and is encouraged.”16

U.S. Preventive Services Task Force Recommendations No U.S. Preventive Services Task Force recommendations on postdischarge outpatient use of

limb compression devices for VTE prophylaxis have been identified.

Medicare National Coverage

There is no national coverage determination (NCD).

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V. DEFINITIONS TOP

N/A

VI. BENEFIT VARIATIONS TOP

The existence of this medical policy does not mean that this service is a covered benefit under

the member's contract. Benefit determinations should be based in all cases on the applicable

contract language. Medical policies do not constitute a description of benefits. A member’s

individual or group customer benefits govern which services are covered, which are excluded,

and which are subject to benefit limits and which require preauthorization. Members and

providers should consult the member’s benefit information or contact Capital for benefit

information.

VII. DISCLAIMER TOP

Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical

advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of

members. Members should discuss any medical policy related to their coverage or condition with their provider

and consult their benefit information to determine if the service is covered. If there is a discrepancy between this

medical policy and a member’s benefit information, the benefit information will govern. Capital considers the

information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law.

VIII. CODING INFORMATION TOP

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The

identification of a code in this section does not denote coverage as coverage is determined by the

terms of member benefit information. In addition, not all covered services are eligible for separate

reimbursement.

Covered when medically necessary:

HCPCS

Code Description

E0650 Pneumatic compressor, nonsegmental home model

E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure

E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure

E0660 Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

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E0666 Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0671 Segmental gradient pressure pneumatic appliance, full leg

E0673 Segmental gradient pressure pneumatic appliance, half leg

E0676 Intermittent limb compression device (includes all accessories), not otherwise specified *If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

ICD-10-

CM

Diagnosis

Codes

Description

M05.051 Felty's syndrome, right hip

M05.052 Felty's syndrome, left hip

M05.061 Felty's syndrome, right knee

M05.062 Felty's syndrome, left knee

M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip

M05.152 Rheumatoid lung disease with rheumatoid arthritis of left hip

M05.161 Rheumatoid lung disease with rheumatoid arthritis of right knee

M05.162 Rheumatoid lung disease with rheumatoid arthritis of left knee

M05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hip

M05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hip

M05.261 Rheumatoid vasculitis with rheumatoid arthritis of right knee

M05.262 Rheumatoid vasculitis with rheumatoid arthritis of left knee

M05.351 Rheumatoid heart disease with rheumatoid arthritis of right hip

M05.352 Rheumatoid heart disease with rheumatoid arthritis of left hip

M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee

M05.362 Rheumatoid heart disease with rheumatoid arthritis of left knee

M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip

M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip

M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee

M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee

M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip

M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip

M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee

M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee

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M05.651 Rheumatoid arthritis of right hip with involvement of other organs and systems

M05.652 Rheumatoid arthritis of left hip with involvement of other organs and systems

M05.661 Rheumatoid arthritis of right knee with involvement of other organs and systems

M05.662 Rheumatoid arthritis of left knee with involvement of other organs and systems

M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems

involvement

M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems

involvement

M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems

involvement

M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems

involvement

M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip

M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip

M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee

M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee

M06.051 Rheumatoid arthritis without rheumatoid factor, right hip

M06.052 Rheumatoid arthritis without rheumatoid factor, left hip

M06.061 Rheumatoid arthritis without rheumatoid factor, right knee

M06.062 Rheumatoid arthritis without rheumatoid factor, left knee

M06.1 Adult-onset Still's disease

M06.251 Rheumatoid bursitis, right hip

M06.252 Rheumatoid bursitis, left hip

M06.261 Rheumatoid bursitis, right knee

M06.262 Rheumatoid bursitis, left knee

M06.351 Rheumatoid nodule, right hip

M06.352 Rheumatoid nodule, left hip

M06.361 Rheumatoid nodule, right knee

M06.362 Rheumatoid nodule, left knee

M06.851 Other specified rheumatoid arthritis, right hip

M06.852 Other specified rheumatoid arthritis, left hip

M06.861 Other specified rheumatoid arthritis, right knee

M06.862 Other specified rheumatoid arthritis, left knee

M08.251 Juvenile rheumatoid arthritis with systemic onset, right hip

M08.252 Juvenile rheumatoid arthritis with systemic onset, left hip

M08.261 Juvenile rheumatoid arthritis with systemic onset, right knee

M08.262 Juvenile rheumatoid arthritis with systemic onset, left knee

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M08.451 Pauciarticular juvenile rheumatoid arthritis, right hip

M08.452 Pauciarticular juvenile rheumatoid arthritis, left hip

M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee

M08.462 Pauciarticular juvenile rheumatoid arthritis, left knee

M08.851 Other juvenile arthritis, right hip

M08.852 Other juvenile arthritis, left hip

M08.861 Other juvenile arthritis, right knee

M08.862 Other juvenile arthritis, left knee

M12.051 Chronic postrheumatic arthropathy [Jaccoud], right hip

M12.052 Chronic postrheumatic arthropathy [Jaccoud], left hip

M12.061 Chronic postrheumatic arthropathy [Jaccoud], right knee

M12.062 Chronic postrheumatic arthropathy [Jaccoud], left knee

M12.551 Traumatic arthropathy, right hip

M12.552 Traumatic arthropathy, left hip

M12.561 Traumatic arthropathy, right knee

M12.562 Traumatic arthropathy, left knee

M15.0 Primary generalized (osteo)arthritis

M15.1 Heberden's nodes (with arthropathy)

M15.2 Bouchard's nodes (with arthropathy)

M15.3 Secondary multiple arthritis

M15.4 Erosive (osteo)arthritis

M15.8 Other polyosteoarthritis

M16.0 Bilateral primary osteoarthritis of hip

M16.11 Unilateral primary osteoarthritis, right hip

M16.12 Unilateral primary osteoarthritis, left hip

M16.2 Bilateral osteoarthritis resulting from hip dysplasia

M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip

M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip

M16.4 Bilateral post-traumatic osteoarthritis of hip

M16.51 Unilateral post-traumatic osteoarthritis, right hip

M16.52 Unilateral post-traumatic osteoarthritis, left hip

M16.6 Other bilateral secondary osteoarthritis of hip

M16.7 Other unilateral secondary osteoarthritis of hip

M17.0 Bilateral primary osteoarthritis of knee

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

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M17.2 Bilateral post-traumatic osteoarthritis of knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee

M17.32 Unilateral post-traumatic osteoarthritis, left knee

M17.4 Other bilateral secondary osteoarthritis of knee

M17.5 Other unilateral secondary osteoarthritis of knee

M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter

for fracture

M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for

fracture

M80.851A Other osteoporosis with current pathological fracture, right femur, initial encounter for

fracture

M80.852A Other osteoporosis with current pathological fracture, left femur, initial encounter for

fracture

M84.451A Pathological fracture, right femur, initial encounter for fracture

M84.452A Pathological fracture, left femur, initial encounter for fracture

M84.551A Pathological fracture in neoplastic disease, right femur, initial encounter for fracture

M84.552A Pathological fracture in neoplastic disease, left femur, initial encounter for fracture

M84.651A Pathological fracture in other disease, right femur, initial encounter for fracture

M84.652A Pathological fracture in other disease, left femur, initial encounter for fracture

S72.021A Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for

closed fracture

S72.021B Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for

open fracture type I or II

S72.021C Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for

open fracture type IIIA, IIIB, or IIIC

S72.022A Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for

closed fracture

S72.022B Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open

fracture type I or II

S72.022C Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open

fracture type IIIA, IIIB, or IIIC

S72.024A Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for

closed fracture

S72.024B Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for


S72.024C Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for


S72.025A Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for

closed fracture

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S72.025B Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for


S72.025C Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for


S72.031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

S72.031B Displaced midcervical fracture of right femur, initial encounter for open fracture type I or II

S72.031C Displaced midcervical fracture of right femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.032A Displaced midcervical fracture of left femur, initial encounter for closed fracture

S72.032B Displaced midcervical fracture of left femur, initial encounter for open fracture type I or II

S72.032C Displaced midcervical fracture of left femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.034A Nondisplaced midcervical fracture of right femur, initial encounter for closed fracture

S72.034B Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type I

or II

S72.034C Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.035A Nondisplaced midcervical fracture of left femur, initial encounter for closed fracture

S72.035B Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type I or

II

S72.035C Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.041A Displaced fracture of base of neck of right femur, initial encounter for closed fracture

S72.041B Displaced fracture of base of neck of right femur, initial encounter for open fracture type I

or II

S72.041C Displaced fracture of base of neck of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.042A Displaced fracture of base of neck of left femur, initial encounter for closed fracture

S72.042B Displaced fracture of base of neck of left femur, initial encounter for open fracture type I or

II

S72.042C Displaced fracture of base of neck of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.044A Nondisplaced fracture of base of neck of right femur, initial encounter for closed fracture

S72.044B Nondisplaced fracture of base of neck of right femur, initial encounter for open fracture type

I or II

S72.044C Nondisplaced fracture of base of neck of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.045A Nondisplaced fracture of base of neck of left femur, initial encounter for closed fracture

S72.045B Nondisplaced fracture of base of neck of left femur, initial encounter for open fracture type I

or II

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S72.045C Nondisplaced fracture of base of neck of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.061A Displaced articular fracture of head of right femur, initial encounter for closed fracture

S72.061B Displaced articular fracture of head of right femur, initial encounter for open fracture type I

or II

S72.061C Displaced articular fracture of head of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.062A Displaced articular fracture of head of left femur, initial encounter for closed fracture

S72.062B Displaced articular fracture of head of left femur, initial encounter for open fracture type I

or II

S72.062C Displaced articular fracture of head of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.064A Nondisplaced articular fracture of head of right femur, initial encounter for closed fracture

S72.064B Nondisplaced articular fracture of head of right femur, initial encounter for open fracture

type I or II

S72.064C Nondisplaced articular fracture of head of right femur, initial encounter for open fracture

type IIIA, IIIB, or IIIC

S72.065A Nondisplaced articular fracture of head of left femur, initial encounter for closed fracture

S72.065B Nondisplaced articular fracture of head of left femur, initial encounter for open fracture type

I or II

S72.065C Nondisplaced articular fracture of head of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.091A Other fracture of head and neck of right femur, initial encounter for closed fracture

S72.091B Other fracture of head and neck of right femur, initial encounter for open fracture type I or

II

S72.091C Other fracture of head and neck of right femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.092A Other fracture of head and neck of left femur, initial encounter for closed fracture

S72.092B Other fracture of head and neck of left femur, initial encounter for open fracture type I or II

S72.092C Other fracture of head and neck of left femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.111A Displaced fracture of greater trochanter of right femur, initial encounter for closed fracture

S72.111B Displaced fracture of greater trochanter of right femur, initial encounter for open fracture

type I or II

S72.111C Displaced fracture of greater trochanter of right femur, initial encounter for open fracture


S72.112A Displaced fracture of greater trochanter of left femur, initial encounter for closed fracture

S72.112B Displaced fracture of greater trochanter of left femur, initial encounter for open fracture type

I or II

S72.112C Displaced fracture of greater trochanter of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

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Page 21

S72.114A Nondisplaced fracture of greater trochanter of right femur, initial encounter for closed

fracture

S72.114B Nondisplaced fracture of greater trochanter of right femur, initial encounter for open


S72.114C Nondisplaced fracture of greater trochanter of right femur, initial encounter for open


S72.115A Nondisplaced fracture of greater trochanter of left femur, initial encounter for closed

fracture

S72.115B Nondisplaced fracture of greater trochanter of left femur, initial encounter for open fracture

type I or II

S72.115C Nondisplaced fracture of greater trochanter of left femur, initial encounter for open fracture


S72.121A Displaced fracture of lesser trochanter of right femur, initial encounter for closed fracture

S72.121B Displaced fracture of lesser trochanter of right femur, initial encounter for open fracture

type I or II

S72.121C Displaced fracture of lesser trochanter of right femur, initial encounter for open fracture


S72.122A Displaced fracture of lesser trochanter of left femur, initial encounter for closed fracture

S72.122B Displaced fracture of lesser trochanter of left femur, initial encounter for open fracture type

I or II

S72.122C Displaced fracture of lesser trochanter of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.124A Nondisplaced fracture of lesser trochanter of right femur, initial encounter for closed

fracture

S72.124B Nondisplaced fracture of lesser trochanter of right femur, initial encounter for open fracture

type I or II

S72.124C Nondisplaced fracture of lesser trochanter of right femur, initial encounter for open fracture


S72.125A Nondisplaced fracture of lesser trochanter of left femur, initial encounter for closed fracture

S72.125B Nondisplaced fracture of lesser trochanter of left femur, initial encounter for open fracture

type I or II

S72.125C Nondisplaced fracture of lesser trochanter of left femur, initial encounter for open fracture


S72.131A Displaced apophyseal fracture of right femur, initial encounter for closed fracture

S72.131B Displaced apophyseal fracture of right femur, initial encounter for open fracture type I or II

S72.131C Displaced apophyseal fracture of right femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.132A Displaced apophyseal fracture of left femur, initial encounter for closed fracture

S72.132B Displaced apophyseal fracture of left femur, initial encounter for open fracture type I or II

S72.132C Displaced apophyseal fracture of left femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

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Page 22

S72.134A Nondisplaced apophyseal fracture of right femur, initial encounter for closed fracture

S72.134B Nondisplaced apophyseal fracture of right femur, initial encounter for open fracture type I

or II

S72.134C Nondisplaced apophyseal fracture of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.135A Nondisplaced apophyseal fracture of left femur, initial encounter for closed fracture

S72.135B Nondisplaced apophyseal fracture of left femur, initial encounter for open fracture type I or

II

S72.135C Nondisplaced apophyseal fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.141A Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture

S72.141B Displaced intertrochanteric fracture of right femur, initial encounter for open fracture type I

or II

S72.141C Displaced intertrochanteric fracture of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.142A Displaced intertrochanteric fracture of left femur, initial encounter for closed fracture

S72.142B Displaced intertrochanteric fracture of left femur, initial encounter for open fracture type I

or II

S72.142C Displaced intertrochanteric fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.144A Nondisplaced intertrochanteric fracture of right femur, initial encounter for closed fracture

S72.144B Nondisplaced intertrochanteric fracture of right femur, initial encounter for open fracture

type I or II

S72.144C Nondisplaced intertrochanteric fracture of right femur, initial encounter for open fracture


S72.145A Nondisplaced intertrochanteric fracture of left femur, initial encounter for closed fracture

S72.145B Nondisplaced intertrochanteric fracture of left femur, initial encounter for open fracture type

I or II

S72.145C Nondisplaced intertrochanteric fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.21XA Displaced subtrochanteric fracture of right femur, initial encounter for closed fracture

S72.21XB Displaced subtrochanteric fracture of right femur, initial encounter for open fracture type I

or II

S72.21XC Displaced subtrochanteric fracture of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.22XA Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture

S72.22XB Displaced subtrochanteric fracture of left femur, initial encounter for open fracture type I or

II

S72.22XC Displaced subtrochanteric fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.24XA Nondisplaced subtrochanteric fracture of right femur, initial encounter for closed fracture

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Page 23

S72.24XB Nondisplaced subtrochanteric fracture of right femur, initial encounter for open fracture

type I or II

S72.24XC Nondisplaced subtrochanteric fracture of right femur, initial encounter for open fracture


S72.25XA Nondisplaced subtrochanteric fracture of left femur, initial encounter for closed fracture

S72.25XB Nondisplaced subtrochanteric fracture of left femur, initial encounter for open fracture type

I or II

S72.25XC Nondisplaced subtrochanteric fracture of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72.321B Displaced transverse fracture of shaft of right femur, initial encounter for open fracture type

I or II

S72.321C Displaced transverse fracture of shaft of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72.322B Displaced transverse fracture of shaft of left femur, initial encounter for open fracture type I

or II

S72.322C Displaced transverse fracture of shaft of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72.324B Nondisplaced transverse fracture of shaft of right femur, initial encounter for open fracture

type I or II

S72.324C Nondisplaced transverse fracture of shaft of right femur, initial encounter for open fracture


S72.325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72.325B Nondisplaced transverse fracture of shaft of left femur, initial encounter for open fracture

type I or II

S72.325C Nondisplaced transverse fracture of shaft of left femur, initial encounter for open fracture


S72.331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture

S72.331B Displaced oblique fracture of shaft of right femur, initial encounter for open fracture type I

or II

S72.331C Displaced oblique fracture of shaft of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture

S72.332B Displaced oblique fracture of shaft of left femur, initial encounter for open fracture type I or

II

S72.332C Displaced oblique fracture of shaft of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.334A Nondisplaced oblique fracture of shaft of right femur, initial encounter for closed fracture

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Page 24

S72.334B Nondisplaced oblique fracture of shaft of right femur, initial encounter for open fracture

type I or II

S72.334C Nondisplaced oblique fracture of shaft of right femur, initial encounter for open fracture


S72.335A Nondisplaced oblique fracture of shaft of left femur, initial encounter for closed fracture

S72.335B Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type

I or II

S72.335C Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.341A Displaced spiral fracture of shaft of right femur, initial encounter for closed fracture

S72.341B Displaced spiral fracture of shaft of right femur, initial encounter for open fracture type I or

II

S72.341C Displaced spiral fracture of shaft of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.342A Displaced spiral fracture of shaft of left femur, initial encounter for closed fracture

S72.342B Displaced spiral fracture of shaft of left femur, initial encounter for open fracture type I or II

S72.342C Displaced spiral fracture of shaft of left femur, initial encounter for open fracture type IIIA,

IIIB, or IIIC

S72.344A Nondisplaced spiral fracture of shaft of right femur, initial encounter for closed fracture

S72.344B Nondisplaced spiral fracture of shaft of right femur, initial encounter for open fracture type I

or II

S72.344C Nondisplaced spiral fracture of shaft of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.345A Nondisplaced spiral fracture of shaft of left femur, initial encounter for closed fracture

S72.345B Nondisplaced spiral fracture of shaft of left femur, initial encounter for open fracture type I

or II

S72.345C Nondisplaced spiral fracture of shaft of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.351A Displaced comminuted fracture of shaft of right femur, initial encounter for closed fracture

S72.351B Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture

type I or II

S72.351C Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture


S72.352A Displaced comminuted fracture of shaft of left femur, initial encounter for closed fracture

S72.352B Displaced comminuted fracture of shaft of left femur, initial encounter for open fracture

type I or II

S72.352C Displaced comminuted fracture of shaft of left femur, initial encounter for open fracture


S72.354A Nondisplaced comminuted fracture of shaft of right femur, initial encounter for closed

fracture

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Page 25

S72.354B Nondisplaced comminuted fracture of shaft of right femur, initial encounter for open


S72.354C Nondisplaced comminuted fracture of shaft of right femur, initial encounter for open


S72.355A Nondisplaced comminuted fracture of shaft of left femur, initial encounter for closed

fracture

S72.355B Nondisplaced comminuted fracture of shaft of left femur, initial encounter for open fracture

type I or II

S72.355C Nondisplaced comminuted fracture of shaft of left femur, initial encounter for open fracture


S72.361A Displaced segmental fracture of shaft of right femur, initial encounter for closed fracture

S72.361B Displaced segmental fracture of shaft of right femur, initial encounter for open fracture type

I or II

S72.361C Displaced segmental fracture of shaft of right femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.362A Displaced segmental fracture of shaft of left femur, initial encounter for closed fracture

S72.362B Displaced segmental fracture of shaft of left femur, initial encounter for open fracture type I

or II

S72.362C Displaced segmental fracture of shaft of left femur, initial encounter for open fracture type

IIIA, IIIB, or IIIC

S72.364A Nondisplaced segmental fracture of shaft of right femur, initial encounter for closed fracture

S72.364B Nondisplaced segmental fracture of shaft of right femur, initial encounter for open fracture

type I or II

S72.364C Nondisplaced segmental fracture of shaft of right femur, initial encounter for open fracture


S72.365A Nondisplaced segmental fracture of shaft of left femur, initial encounter for closed fracture

S72.365B Nondisplaced segmental fracture of shaft of left femur, initial encounter for open fracture

type I or II

S72.365C Nondisplaced segmental fracture of shaft of left femur, initial encounter for open fracture


S72.391A Other fracture of shaft of right femur, initial encounter for closed fracture

S72.391B Other fracture of shaft of right femur, initial encounter for open fracture type I or II

S72.391C Other fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S72.392A Other fracture of shaft of left femur, initial encounter for closed fracture

S72.392B Other fracture of shaft of left femur, initial encounter for open fracture type I or II

S72.392C Other fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or

IIIC

S72.8X1A Other fracture of right femur, initial encounter for closed fracture

S72.8X1B Other fracture of right femur, initial encounter for open fracture type I or II

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Page 26

S72.8X1C Other fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC

S72.8X2A Other fracture of left femur, initial encounter for closed fracture

S72.8X2B Other fracture of left femur, initial encounter for open fracture type I or II

S72.8X2C Other fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC

S79.011A Salter-Harris Type I physeal fracture of upper end of right femur, initial encounter for

closed fracture

S79.012A Salter-Harris Type I physeal fracture of upper end of left femur, initial encounter for closed

fracture

S79.091A Other physeal fracture of upper end of right femur, initial encounter for closed fracture

S79.092A Other physeal fracture of upper end of left femur, initial encounter for closed fracture

Z47.1 Aftercare following joint replacement surgery

Z96.641 Presence of right artificial hip joint

Z96.642 Presence of left artificial hip joint

Z96.643 Presence of artificial hip joint, bilateral

Z96.651 Presence of right artificial knee joint

Z96.652 Presence of left artificial knee joint

Z96.653 Presence of artificial knee joint, bilateral *If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

IX. REFERENCES TOP

1. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery

patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College

of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2

Suppl):e278S-325S. PMID 22315265

2. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients:

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest

Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2

Suppl):e227S-277S. PMID 22315263

3. HAS-BLED Score for Major Bleeding Risk. http://www.mdcalc.com/has-bled-score-for-major-

bleeding-risk/. Accessed March 31, 2016.

4. Fisher WD. Impact of venous thromboembolism on clinical management and therapy after hip

and knee arthroplasty. Can J Surg. Oct 2011;54(5):344-351. PMID 21774881

5. Committee on Practice Bulletins--American College of Obstetricians and Gynecologists.

ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary

embolism. Obstet Gynecol. Aug 2007;110(2 Pt 1):429-440. PMID 17666620

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6. Froimson MI, Murray TG, Fazekas AF. Venous thromboembolic disease reduction with a

portable pneumatic compression device. J Arthroplasty. Feb 2009;24(2):310-316. PMID

18534456

7. O'Connell S, Bashar K, Broderick BJ, et al. The Use of Intermittent Pneumatic Compression

in Orthopedic and Neurosurgical Postoperative Patients: A Systematic Review and Meta-

analysis. Ann Surg. Dec 29 2015. PMID 26720432

8. Zareba P, Wu C, Agzarian J, et al. Meta-analysis of randomized trials comparing combined

compression and anticoagulation with either modality alone for prevention of venous

thromboembolism after surgery. Br J Surg. Aug 2014;101(9):1053-1062. PMID 24916118

9. Sobieraj DM, Coleman CI, Tongbram V, et al. Comparative effectiveness of combined

pharmacologic and mechanical thromboprophylaxis versus either method alone in major

orthopedic surgery: a systematic review and meta-analysis. Pharmacotherapy. Mar

2013;33(3):275-283. PMID 23401017

10. Kakkos SK, Warwick D, Nicolaides AN, et al. Combined (mechanical and pharmacological)

modalities for the prevention of venous thromboembolism in joint replacement surgery. J

Bone Joint Surg Br. Jun 2012;94(6):729-734. PMID 22628585

11. Ho KM, Tan JA. Stratified meta-analysis of intermittent pneumatic compression of the lower

limbs to prevent venous thromboembolism in hospitalized patients. Circulation. Aug 27

2013;128(9):1003-1020. PMID 23852609

12. Sobieraj-Teague M, Hirsh J, Yip G, et al. Randomized controlled trial of a new portable calf

compression device (Venowave) for prevention of venous thrombosis in high-risk

neurosurgical patients. J Thromb Haemost. Feb 2012;10(2):229-235. PMID 22188037

13. Alliance FC. Hospital Discharge Planning: A Guide for Families and Caregivers.

https://www.caregiver.org/hospital-discharge-planning-guide-families-and-caregivers.

Accessed March 31, 2016.

14. Boutwell A, Hwu S. Effective Interventions to Reduce Rehospitalizations: A Survey of the

Published Evidence Institute for Healthcare Improvement. 2009.

15. American Academy of Orthopaedic Surgeons (AAOS). Preventing venous thromboembolic

disease in patients undergoing elective hip and knee arthroplasty. 2011; www.guideline.gov.

Accessed February 18, 2016.

16. American Orthopaedic Foot & Ankle Society (AOFAS). Position Statement: The Use of

VTED Prophylaxis in Foot and Ankle Surgery. 2013; http://www.aofas.org/medical-

community/

Other:

Durable Medical Equipment Regional Carrier (DME MAC JA) Region JA Noridian Healthcare

Solutions LLC Local Coverage Determination (LCD) (L33829Pneumatic Compression Devices.

Effective 07/01/16. [Website]:

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https://www.cms.gov/medicare-coverage-database/indexes/lcd-

list.aspx?Cntrctr=139&ContrVer=2&CntrctrSelected=139*2&name=Noridian+Healthcare+So

lutions%2c+LLC+(19003%2c+DME+MAC)&s=6&DocType=Active&bc=AggAAAAAAAAAAA

%3d%3d&#ResultsAnchor Accessed July 6, 2016.

X. POLICY HISTORY TOP

MP 6.053 CAC 9/24/13 New policy partially adopting BCBSA with addition of

coverage criteria for after non-major orthopedic surgery of the lower

extremity. Previously silent regarding use of compression pumps for

thromboembolism prophylaxis. Now considered medically necessary with

criteria.

CAC 9/30/14 Consensus review. Title changed to: Postsurgical Outpatient

Use of Limb Compression Devices for Venous Thromboembolism

Prophylaxis. “Pneumatic” removed from policy statements and policy title.

Major nonorthopedic surgery changed to “major nonorthopedic surgery or

nonmajor orthopedic surgery. References and rationale updated. Codes

reviewed.

CAC 7/21/15 Coding reviewed/unranged

CAC 9/29/15 Consensus review. No change to the policy statements.

Reference and rationale updated. Added Medicare variation to reference

Durable Medical Equipment Regional Carrier (DME MAC A) Region A

Local Coverage Determination (LCD) L11503 Pneumatic Compression

Devices. Coding Reviewed.

CAC 7/26/16 Consensus review. Policy title changed to “Postsurgical Home

Use of Limb Compression Devices for Venous Thromboembolism

Prophylaxis” In the title, “Outpatient” was deleted and “Home” added. Policy

statements and guidelines rewritten for clarity; intent of statements is

unchanged. Reference and rationale updated. Medicare variation changed to

refer to Noridian LCD L33829. Coding reviewed.

Admin Update 1/1/17 Variation reformatting.

Top

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®,

Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield

Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=139&ContrVer=2&CntrctrSelected=139*2&name=Noridian+Healthcare+Solutions%2c+LLC+(19003%2c+DME+MAC)&s=6&DocType=Active&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor




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Postsurgical Home Use of Limb Compression Devices for ... · prophylaxis be provided rather than no thromboprophylaxis.1 The guidelines further recommend the use of pharmacologic