A6577 Custom grad cm sleeve heavyGradient compression arm sleeve, custom, heavy weight, each
Status X: statutory exclusion, not paid under the PFS.
A6577 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Complex Regional Pain Syndrome (CRPS): Treatments (0447) Ketamine metabolite (2R,6R)-hydroxynorketamine, metformin, topical ketamine, Topical dimethyl sulfoxide, Anakinra, Sarilumab - | not covered (range A6572-A6588) | Jul 16, 2026 | payer document |
| Aetna | External Breast Prosthesis (0097) | covered if criteria are met | Jan 15, 2026 | payer document |
| Aetna | Lymphedema (0069) | covered if criteria are met | Feb 25, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Garments (L.1.04.400) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Compression Garments_Stockings PAYMENT POLICY | 2 | covered if criteria are met | Apr 1, 2026 | payer document |
Prior authorization required or conditional in MA, NY, OH, VA, WA.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.