Note: Aetna's standard HMO-based plans (HMO, QPOS, U.S. Access, Golden Medicare) do not cover graded compression stockings or non-elastic binders because they are considered an outpatient consumable or disposable supply. Please check benefit plan descriptions for details. HMO-based plans cover inflatable compression garments only for selected persons with lymphedema. (See CPB 069 - Lymphedema Treatments)

Inflatable compression garments*, non-elastic binders**, or individually fitted prescription graded compression stockings*** are considered medically necessary for members who have any of the following medical conditions:

1. Treatment of any of the following complications of chronic venous insufficiency:

   1. Varicose veins (except spider veins)
   2. Stasis dermatitis (venous eczema)
   3. Venous ulcers (stasis ulcers)
   4. Venous edema

   5. Lipodermatosclerosis

2. Prevention of thrombosis in immobilized persons (e.g., immobilization due to surgery, trauma, general debilitation, etc.)
3. Post thrombotic syndrome (post phlebitic syndrome)
4. Selected persons with chronic lymphedema (see CPB 069 - Lymphedema Treatments)
5. Edema following surgery, fracture, burns, or other trauma
6. Post sclerotherapy****
7. Postural hypotension
8. Severe edema in pregnancy
9. Edema accompanying paraplegia, quadriplegia, etc.

These compression garments for the legs are considered experimental and investigational for all other indications.

The use of abdominal compression garments for the management of truncal edema is considered experimental and investigational.  See CPB 069 - Lymphedema Treatments.

* The above reference to inflatable compression garments (e.g., Flowtron Compression Garment, Jobst Pneumatic Compressor) also includes the pump needed to inflate the compression garment. For Aetna's clinical policy on intermittent and sequential compression pumps for lymphedema, see CPB 069 - Lymphedema Treatments, and CPB 500 - Intermittent Pneumatic Compression Devices for the Legs.

**Aetna considers non-elastic leg binders (e.g., LegAssist, CircAid, Reid Sleeve) medically necessary for members who meet the selection criteria for pressure gradient support stockings listed above. Non-elastic leg binders are similar to graded compression stockings in that they provide static compression of the leg, but unlike graded compression stockings, they do not use elastic, but use adjustable Velcro or buckle straps.

***Applies only to pre-made or custom-made pressure gradient support stockings (e.g., Jobst, SigVarus, Venes, Juzo, etc.) that have a pressure of 18 mm Hg or more, that require a physician's prescription, and that require measurements for fitting.

****Only pressure gradient support stockings are considered medically necessary for this indication; inflatable compression garments have no proven value for this indication.

Stockings purchased over the counter without a prescription which have a pressure of less than 20 mm Hg (e.g., elastic stockings, 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. Note: These OTC stockings are also not covered because they are not primarily medical in nature.

Replacements:

Replacements are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member's physical condition. For pressure gradient support stockings, no more than four replacements per year are considered medically necessary for wear.

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).

Contraindications:

Compression garments are considered experimental and investigational for members with severe peripheral arterial disease or septic phlebitis because they are contraindicated in these conditions.

Compression garments are usually made of elastic material, and are used to promote venous or lymphatic circulation. Compression garments worn on the legs can help prevent deep vein thrombosis and reduce edema, and are useful in a variety of peripheral vascular conditions. Compression garments can come in varying degrees of compression. The higher degrees require a physician's prescription.