VTE prophylaxis after major non-orthopedic surgery or non-major orthopedic surgery in individuals who are at moderate or high risk of VTE (see Professional Statements and Societal Positions) with a contraindication to pharmacological agents, (i.e., at high risk for bleeding).total hip arthroplasty, total knee arthroplasty, hip fracture surgery) in individuals with a contraindication to pharmacological agents, (i.e., at high risk for bleeding) Venous thromboembolism (VTE) prophylaxis after major orthopedic surgery (e.g. In-home use of limb compression devices for the following indications may be considered medically necessary for The trial of conservative therapy must include The trial of conservative therapy must includeĪ compression bandage system or compression garment Ĭhronic venous insufficiency (CVI) of the lower extremities with non-healing venous stasis ulcer(s) after a six (6) month trial of conservative therapy directed by the treating physician. Lymphedema treatment (pumps and appliances) of the arm or leg that has failed a four (4) week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. Segmented or non-segmented pneumatic compression devices without calibrated gradient pressure for home use may be considered medically necessary for the treatment of
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