Forms & downloads

Compression garments

• Signed, dated Rx — garment type, compression level (mmHg), length or style, quantity
• Diagnosis with ICD-10 code
• Most recent progress note (past 6 months) — needed when insurance applies (lymphedema, or a venous ulcer under care)
• Lymphedema garments: the diagnosis must be in the treating provider’s own note (MD, DO, NP, PA or CNS). A therapist note can’t be used for the diagnosis, even if co-signed. The therapist note covers each item’s manufacturer, model, quantity, size and color.
• Measurements, if your clinic measured — otherwise we measure in our store
• Face sheet with demographics, insurance, and a copy of the insurance card

Forms: Rx — legs · Rx — arms · measuring forms

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