Ordering a compression pump (E0651 / E0652)

Compression pumps (E0651 / E0652)

All notes and signed documents must be dated within the past 6 months.

• Face sheet with primary and secondary insurance (member ID and group number) and a copy of the insurance card, front and back
• Signed, dated progress notes with a lymphedema diagnosis (I89.0, I97.2 or Q82.0), a statement that it is chronic and persistent, and at least 4 weeks of failed conservative therapy — elevation, exercise, medical-grade compression, diet, and MLD if applicable
• Limb measurements with dates — at baseline and after the 4-week trial
• Signed Letter of Medical Necessity on letterhead, with the same rationale
• Signed addendum, if the progress notes don't include the required language
• Signed order (SWO) — HCPCS E0651 or E0652 plus two E0667 sleeves, frequency and duration of use, provider NPI and signature
• E0652 only: the physician must document why a calibrated pump is needed over E0651, specific to this patient. Listing “unique characteristics” without context will be denied.

Forms: pump Rx form · pump documentation guide