E0655 Pneumatic appliance half armNon-segmental pneumatic appliance for use with pneumatic compressor, half arm
4 of 4 payer prior-auth lists that name E0655 require prior authorization or set conditions: Humana, Rocky Mountain Health Plans, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| 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 |
E0655 appears in 25 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 | 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 | 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) Single Compartment Nonprogrammable Appliances (used in conjunction with E0650) | covered if criteria are met | Sep 21, 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 | Pneumatic Compression Devices (2026T0563X) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Pneumatic Compression Devices (CS097.T) | listed, no stance | Jul 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 |
Prior authorization required or conditional in CO, MA, MS, NY, OH, VA, WV.
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.