`E0652` Pneum compres w/cal pressure

Pneumatic compressor, segmental home model with calibrated gradient pressure

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 1 units per day (clinical), rationale: Nature of Equipment

Medicare pricing for E0652

DMEPOS fee schedule, July 2026 (DME26-C)

NU (purchased, new), inexpensive or routinely purchased (IN): non-rural $6,422.01 to $7,555.31 in the contiguous states; $7,168.22 to $9,406.70 in AK, HI, PR and VI; ceiling $7,555.31, floor $6,422.01
RR (rental), inexpensive or routinely purchased (IN): non-rural $634.69 to $746.69 in the contiguous states; $716.78 to $1,127.76 in AK, HI, PR and VI; ceiling $746.69, floor $634.69
UE (purchased, used), inexpensive or routinely purchased (IN): non-rural $4,812.21 to $5,661.42 in the contiguous states; $5,100.36 to $7,055.19 in AK, HI, PR and VI; ceiling $5,661.42, floor $4,812.21

Payer policies and prior authorization for E0652

86 of 89 payer prior-auth lists that name E0652 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, HealthSpring, Humana, Medicare, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Medicare	DMEPOS Master List (items potentially subject to PA)	All	prior auth under conditions	On the Master List; PA only if CMS selects it for the Required List	Jul 30, 2026	Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements
Medicare	DMEPOS Required Prior Authorization	All	prior auth required		Apr 13, 2026	Required Prior Authorization List
Blue Cross and Blue Shield of New Mexico	Turquoise Care (New Mexico Medicaid)	NM	prior auth required		Oct 1, 2026	New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Mar 1, 2026	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	FL	prior auth required		Jan 1, 2027	1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List
Humana	Humana Healthy Horizons	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	LA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Oct 1, 2019	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Oct 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth under conditions	Prior authorization is required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth under conditions	If the brand is found on the PDL, please redirect as a pharmacy benefit to OptumRx at 1-866-328- 3108 Prior authorization is required only for the codes listed with a retail purchase or a cumulative r	Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500 Prosthetics are not DME — see orthotics and prosthetics.	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see orthotics and prosthetics.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – see orthotics and prosthetics	Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth under conditions	site of care: outpatient	Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see Orthotics and Prosthetics.	Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $750 Prosthetics are not DME – see Orthotics and prosthetics.	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	North Carolina Medicaid	NC	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – see Orthotics and prosthetics.	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	TennCare	TN	prior auth under conditions	Prior authorization is required only for DME codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500 Prosthetics are not DME – see Orthotics and prosthetics.	Apr 1, 2019	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth under conditions	Prior authorization is required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Apr 1, 2019	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	Prior authorization is required only for codes listed with a retail purchase or a cumulative rental cost of more than $500.	Apr 1, 2019	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Apr 1, 2019	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see orthotics and prosthetics.	Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see Orthotics and prosthetics.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026

Payer coverage policies that name E0652

E0652 appears in 29 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Capital Blue Cross, Cigna, Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Compression Garments for the Legs (0482)	covered if criteria are met	Jul 29, 2026	payer document
Aetna	Cryoanalgesia and Therapeutic Cold (0297)	not covered	Apr 14, 2026	payer document
Aetna	Intermittent Pneumatic Compression Devices (0500)	covered if criteria are met	Jul 10, 2026	payer document
Aetna	Lymphedema (0069)	covered if criteria are met	Feb 25, 2026	payer document
Anthem	Compression Devices for Lymphedema (CG-DME-06)	covered if criteria are met	Nov 6, 2025	payer document
Anthem	Compression Devices for Lymphedema (CG-DME-06)	not covered	Nov 6, 2025	payer document
Anthem	Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting (CG-DME-46)	not covered	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Pneumatic Compression Pumps For Treatment Of Lymphedema And Venous Ulcers	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Postsurgical Home Use Of Limb Compression Devices For Venous Thromboembolism Prophylaxis	covered if criteria are met (range E0650-E0675)		payer document
Blue Cross Blue Shield of Massachusetts	Pneumatic Compression Pumps for Treatment of Lymphedema (354)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Compression Pumps for Treatment of Lymphedema and Venous Ulcers (CAM 10118) E0651 \| Pneumatic compressor, non-segmental home model	listed, no stance	May 1, 2026	payer document
BlueCross BlueShield of South Carolina	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis (CAM 10128)	listed, no stance (range E0650-E0673)	Aug 1, 2026	payer document
Capital Blue Cross	Compression Devices for Treatment of Lymphedema and Peripheral Vascular Disease (MP 6.013) Procedure Codes	covered if criteria are met	Sep 1, 2026	payer document
Cigna	Compression Devices (0354)	covered if criteria are met	May 15, 2026	payer document
Premera Blue Cross	Compression Pumps for Treatment of Lymphedema and Venous Ulcers (1.01.18) Multichamber Programmable Pumps	covered if criteria are met	Sep 21, 2026	payer document
Premera Blue Cross	Cooling Devices Used in the Outpatient Setting (1.01.538)	listed, no stance	Jul 13, 2026	payer document
Regence	Postsurgical Home Use of Limb Compression Devices (Durable Medical Equipment 90)	listed, no stance (range E0650-E0673)	Dec 1, 2025	payer document
UnitedHealthcare	Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid (MMP028.23) Supply* \| asthma management program.	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Pneumatic Compression Devices (CS097.T)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (2026T0563X)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Idaho Only) (CS097ID.E)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Kansas Only) (CS097KS.04)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Kentucky Only) (CS097KY.10)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Nebraska Only) (CS097NE.T)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for New Jersey Only) (CS097NJ.S)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for New Mexico Only) (CS097NM.D)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for North Carolina Only) (CSNCT0563.09)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Ohio Only) (CS097OH.E)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Pennsylvania Only) (CS097PA.S)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pneumatic Compression Devices (for Tennessee Only) (CS097TN.T)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Oct 1, 2026: PA removed, Rocky Mountain Health Plans
Feb 1, 2026: PA added, UnitedHealthcare
Aug 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, IL, KY, LA, MA, MD, MS, NE, NY, VA, VT, WV.

AZ: $6659.03 (dme), effective Oct 1, 2026
CO: $4213.19 (chp_plus, non-facility), effective Jul 1, 2026
FL: $395.93 (dme), effective Jul 1, 2026
IL: $1731.68 (dme), effective Jan 1, 2026
IN: $6284.71 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2025
KY: $681.67 (dme), effective Jan 1, 2026
LA: $5217.63 (dme), effective May 1, 2014
MD: $6347.15 (dme), effective Apr 1, 2026
MS: $17.13 (comprehensive), effective Jul 1, 2026
NE: $6610.98 (dme), effective Jul 1, 2026
NY: $3807.53 (dme), effective Jul 1, 2026
OH: $5046.00 (dme), effective Jan 1, 2024
OK: $7555.31 (dme), effective Jan 1, 2026
TX: $4170.41 (dmepos_tos_9_e_j_l_and_r, Home Health Dme), effective Apr 1, 2013
VA: $5779.81 (dme), effective Dec 1, 2026
VT: $6333.13 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

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.

E0652 Pneum compres w/cal pressure