HCPCS Level II › E codes E0657 Segmental pneumatic chestSegmental pneumatic appliance for use with pneumatic compressor, chest
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 (policy), rationale: Anatomic Consideration Medicare pricing for E0657 DMEPOS fee schedule, July 2026 (DME26-C) RR (rental), capped rental (CR): non-rural $77.37 in the contiguous states; $77.37 to $92.81 in AK, HI, PR and VI; ceiling $77.37, floor $65.76 Payer policies and prior authorization for E0657 20 of 22 payer prior-auth lists that name E0657 require prior authorization or set conditions: 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 Michigan, Molina Healthcare of New Mexico, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Rocky Mountain Health Plans, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source 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 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 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 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 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 Michigan Exchange MI prior auth required Jul 1, 2021 Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 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 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 Utah Medicare Advantage UT prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 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 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 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
Payer coverage policies that name E0657 E0657 appears in 12 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.
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) not covered Nov 6, 2025 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 Nonprogrammable Appliances (used in conjunction with E0651) 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
Recent prior-auth changes Jan 1, 2027: PA added, Humana Aug 1, 2026: PA removed, HealthSpring Jul 1, 2026: PA removed, Rocky Mountain Health Plans Jan 1, 2026: PA removed, Molina Healthcare of Michigan Jan 1, 2026: PA removed, Molina Healthcare of Michigan Mar 1, 2025: PA removed, Rocky Mountain Health Plans Sep 1, 2024: PA removed, Blue Shield of California Promise Health Plan Jan 1, 2023: PA removed, Molina Healthcare of Ohio Medicaid fee-for-service Prior authorization required or conditional in CO, IL, KY, LA, MA, NY, OH, VA, VT.
AZ: $355.31 (dme), effective Oct 1, 2026 CO: $597.02 (chp_plus, non-facility), effective Jul 1, 2026 IL: $556.56 (dme), effective Jan 1, 2026 IN: $64.47 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KY: $6.64 (dme), effective Jan 1, 2026 NE: $67.69 (dme), effective Jul 1, 2026 NY: $577.52 (dme), effective Jul 1, 2026 OH: $606.80 (dme), effective Jan 1, 2026 VA: $731.09 (dme), effective Dec 1, 2026 VT: $0.00 (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.