Note: Aetna's standard benefit plans do not cover graded compression stockings or non-elastic binders because they are considered an outpatient consumable or disposable supply. Compression garments are considered experimental and investigational for members with severe peripheral arterial disease or septic phlebitis because they are contraindicated in these conditions.Note: These OTC stockings are also not covered because they are not primarily medical in nature Stockings purchased over the counter without a prescription which have a pressure of less than 20 mm Hg (e.g., elastic stockings, support hose, surgical leggings, anti-embolism stockings (Ted hose) or pressure leotards) are considered experimental and investigational because these supplies have not been proven effective in preventing thromboembolism.

Management of spasticity following stroke.Management of pain during post-natal care.Management of delayed-onset muscle soreness.Improvement of knee proprioception in rehabilitation setting.Improvement of functional performance in individuals with Parkinson disease.Two pairs of compression stockings are considered medically necessary in the initial purchase (the 2nd pair is for use while the 1st pair is in the laundry).Ĭompression garments for the legs are considered experimental and investigational for the following indications (not an all-inclusive list) because the effectiveness for these indications has not been established:.For pressure gradient support stockings, no more than 4 replacements per year are considered medically necessary for wear. Replacements are considered medically necessary when the compression garment can not be repaired or when required due to a change in the member's physical condition.Silver impregnated compression stockings are considered not medically necessary because there is insufficient evidence that silver impregnated compression stockings are superior to standard compression stockings.Prevention of thrombosis in immobilized persons (e.g., immobilization due to surgery, trauma, general debilitation, etc.).Post-thrombotic syndrome (post-phlebitic syndrome).Persons with lymphedema (see CPB 0069 - Lymphedema).Edema following surgery, fracture, burns, or other trauma.Edema accompanying paraplegia, quadriplegia, etc.Treatment of any of the following complications of chronic venous insufficiency:.This Clinical Policy Bulletin addresses compression garments for the legs.Īetna considers inflatable compression garments Footnote*, non-elastic binders Footnote**, or individually fitted prescription graded compression stockings Footnote*** as medically necessary for members who have any of the following medical conditions: Number: 0482 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

Leg compression wraps for lymphedema