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Excellus BlueCross BlueShieldCommercial · Coverage · Durable Medical Equipment & Supplies · NY · Orthopedics, General SurgeryMedium impact

Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis 1.01.51

Effective date
Sep 17, 2026
Identified
Jun 20, 2026

Summary

Pneumatic compression devices are considered medically appropriate for venous thromboembolism prophylaxis in the home after major surgery, described as orthopedic, abdominal, pelvic, cancer, and trauma procedures with moderate to high postoperative VTE risk, excluding minor outpatient procedures with immediate return to ambulation. This applies when pharmacological prophylaxis is contraindicated because of an established risk factor documented in the medical records, with post-surgical use up to 30 days. Use of a pneumatic compression device for VTE prevention in any other situation is considered not medically necessary. The current effective date is September 17, 2026, and the most recent annual review kept the policy intent unchanged.

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What to do

Action · 6 steps
01Already effective September 17, 2026: Billing team, before billing home pneumatic compression for VTE prophylaxis, confirm the device is used after major surgery of the type listed (orthopedic, abdominal, pelvic, cancer, or trauma procedures), and not after a minor outpatient procedure with immediate return to ambulation.
02Confirm the medical record documents an established risk factor that makes pharmacological prophylaxis contraindicated, such as a risk for bleeding.
03Confirm post-surgical use is up to 30 days.
04The policy guideline lists general bleeding risk factors including previous major bleeding, severe renal failure, concomitant antiplatelet agent, and surgical factors such as difficult-to-control surgical bleeding, extensive surgical dissection, and revision surgery.
05Major orthopedic surgery includes total hip arthroplasty, total knee arthroplasty, or hip fracture surgery.
06Codes may not be covered under all circumstances.

Codes mentioned

E0650E0651E0652E0660E0666E0667E0669E0671E0673E0676

Original notice

Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis 1.01.51
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs

Excellus BlueCross BlueShield policiesNY policy changesOrthopedicsGeneral SurgeryCode E0650Code E0651Code E0652Code E0660Code E0666Code E0667Code E0669Code E0671Code E0673Code E0676

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