Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Compression devices without a cryotherapy component, such as the NormaTec MVP, NormaTec Pulse and NormaTec Pulse Pro, are not covered for home use, because these devices are considered personal appliances and are not authorized per WAC 296-20-1102.

These compression devices when used in a clinical setting are not covered.
The coverage decision applies to compression devices without a cryotherapy component, including but not limited to:

• NormaTEC MVP
• NormaTec Pulse
• NormaTec Pulse Pro

These compression devices are classified as a powered inflatable tube massager by the Food and Drug Administration, which is intended to temporarily relieve minor muscle aches and/or pains, and to temporarily increase circulation to the treated areas. There is a lack of published scientific evidence on safety and effectiveness of these devices used as treatments for a medical condition.

Note that these devices are not approved for marketing or use as a pneumatic compression device to treat lymphedema and chronic venous insufficiency or to prevent deep vein thrombosis. It is not appropriate to bill CPT® code 97016 (vasopneumatic device) for compression devices used in a therapy session. This CPT® code is only applicable for clinic-based use of vasopneumatic devices classified by the Food and Drug Administration as Cardiovascular Therapeutic Devices, Compressible limb sleeve.