Anthem Blue Cross and Blue Shield Virginia policy
CG-DME-06 Compression Devices for Lymphedema
CG-DME-06 Compression Devices for Lymphedema is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-DME-06). It lists 26 CPT or HCPCS codes, 24 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-DME-06
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| E0650 | On the list | Pneuma Compresor Non-Segment | Policies naming E0650 |
| E0651 | On the list | Pneum Compressor Segmental | Policies naming E0651 |
| E0652 | On the list | Pneum Compres W/Cal Pressure | Policies naming E0652 |
| E0655 | On the list | Pneumatic Appliance Half Arm | Policies naming E0655 |
| E0656 | On the list | Segmental pneumatic appliance for use with pneumatic compressor, trunk | Policies naming E0656 |
| E0657 | On the list | Segmental pneumatic appliance for use with pneumatic compressor, chest | Policies naming E0657 |
| E0658 | On the list | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest | Policies naming E0658 |
| E0659 | Not listed | Policies naming E0659 | |
| E0660 | On the list | Pneumatic Appliance Full Leg | Policies naming E0660 |
| E0665 | On the list | Pneumatic Appliance Full Arm | Policies naming E0665 |
| E0666 | On the list | Pneumatic Appliance Half Leg | Policies naming E0666 |
| E0667 | On the list | Seg Pneumatic Appl Full Leg | Policies naming E0667 |
| E0668 | On the list | Seg Pneumatic Appl Full Arm | Policies naming E0668 |
| E0669 | On the list | Seg Pneumatic Appli Half Leg | Policies naming E0669 |
| E0670 | On the list | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk | Policies naming E0670 |
| E0671 | On the list | Pressure Pneum Appl Full Leg | Policies naming E0671 |
| E0672 | On the list | Pressure Pneum Appl Full Arm | Policies naming E0672 |
| E0673 | On the list | Pressure Pneum Appl Half Leg | Policies naming E0673 |
| E0677 | On the list | Non-pneumatic sequential compression garment, trunk | Policies naming E0677 |
| E0678 | On the list | Non-pneumatic sequential compression garment, full leg | Policies naming E0678 |
| E0679 | On the list | Non-pneumatic sequential compression garment, half leg | Policies naming E0679 |
| E0680 | On the list | Non-pneumatic compression controller with sequential calibrated gradient pressure | Policies naming E0680 |
| E0681 | On the list | Non-pneumatic compression controller without calibrated gradient pressure | Policies naming E0681 |
| E0682 | On the list | Non-pneumatic sequential compression garment, full arm | Policies naming E0682 |
| E0683 | On the list | Non-pneumatic, non-sequential, peristaltic wave compression pump | Policies naming E0683 |
| E1399 | Not listed | Policies naming E1399 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list