By Robert (Bob) Weiss, MS, LE Legislative Advocate
While Congress struggles with the mammoth problem of healthcare reform, and the long-term existence of Medicare remains uncertain, we at NLN are continuing our decade-long struggle to make every change we can that will result in better access to quality care for the lymphedema patient. Our efforts are not limited to Medicare, but we recognize that changes to Medicare ultimately influence changes to all other coverage.
There are many different approaches that have been taken over the years to effect an improvement in Medicare coverage of lymphedema. They are complementary and attack different problems at different levels. Some seek to change policy within the current Medicare law (Title XVIII of the Social Security Act) and other approaches involve the passage of new laws.
We have been requesting for over ten years that CMS perform a National Coverage Analysis (NCA) leading to a National Coverage Determination (NCD) or Local Coverage Determinations (LCDs) for lymphedema treatment. This could fix some existing problems by modifying Medicare policies within current law. Some of these problems concern: confusing and missing billing and coding for bandaging; patient education on home lymphedema care (such as is provided for the diabetes patient); and an inadequate pneumatic compression pump NCD which is medically incorrect and is virtually not coordinated with the primary treatment modalities of MLD, exercise, and compression. In August of 2000 I submitted a formal proposed draft of an LMRP for Complex Decongestive Therapy to the Coverage and Analysis Group (CAG) of HCFA, the predecessor to CMS, for consideration. A separate and slightly different version was sent by NLN a few months later. Neither of these proposed policies was adopted.
We are currently planning to submit a draft LCD for the treatment of lymphedema separate from the LCDs on Physical Medicine and Rehabilitation, and to also provide comments and a redraft of L28290 LCD for Physical Medicine and Rehabilitation Policy.
The November 18 MEDCAC meeting was a very important forward step in this process of modifying policy within the current regulations. The MEDCAC meeting, the first in ten years to be dedicated to lymphedema treatment, provided us with expert opinion that existing evidence gives reasonable confidence that the following lymphedema treatment modalities improve the health of lymphedema patients:
a. Complete decongestive therapy (CDT) comprising manual lymph drainage, compression bandaging and garments, exercises and skin care;
b. CDT in conjunction with a sequential pump;
c. Compression bandage systems and compression garments; and
d. Sequential pumps.
This meeting established confidence that the commonly-used protocols of CDT are effective. Some of these protocols are already covered by Medicare and others are not, but the coverage documentation is fragmented, not coordinated and incomplete, and can be corrected within current statutes. Presumably that will be the next step to be taken by the CMS Coverage and Analysis Group, using the upcoming recommendations of the MEDCAC.
I have been assisting Medicare Beneficiaries in their appeals of denials of coverage for their compression garments and bandages over the last six years, and believe that a "tipping point" may have been reached in my arguments that these items, when used in the compression treatment of lymphedema, meet the statutory and CMS definitions of "prosthetic devices". Administrative Law Judges and Hearing Officers in twenty-two cases have agreed to date.
HCPCS codes are a disaster when it comes to coding items used daily for control and treatment of lymphedema. Thousands of patients are being unjustly denied coverage based on Medicare Contractors' lack of understanding of the concept of "benefit categories". In December 2006 I submitted a formal request for HCPCS coding changes for the materials commonly used in the treatment of lymphedema. The request covered compression bandages, compression garments and pads and compression devices. The request was to place these items in the L-code group since in their use in the compression therapy of lymphedema they meet the definition of "prosthetic device" benefits, and should not be coded with A-codes, E-codes and S-codes which are used for other benefit categories. I also requested new codes for items that were not listed or which had groupings which were too wide, and caused reimbursement problems to manufacturers and suppliers. The request was denied on the basis that there was no need for new codes.
But there are additional deficiencies in Medicare coverage that cannot be fixed within current statutes. It is the purpose of the Lymphedema Diagnosis and Treatment Cost-Saving Bill of 2010, which will hopefully have a bill number by the time you read this column, to look at the entire problem of Medicare coverage of lymphedema treatment according to best medical knowledge. The bill will modify the statutes to allow CMS to make all of the necessary changes and issue a policy covering all of the modalities of complex decongestive therapy (CDT) and pneumatic sequential devices in a coordinated manner. Examples of the changes to Title XVIII included in this bill are: removing the Congressionally-imposed lymphedema therapy limits or reinstallation of the exception process when medically necessary; instituting lymphedema competency requirements for therapists who perform lymphedema therapy; instituting certification requirements for those who fit custom garments and provide bandaging services; definition of a new benefit category of "compression therapy" which may be used in wound care and venous insufficiency as well as lymphedema; and reimbursement of lymphedema-trained nurses, chiropractors, osteopathic doctors, medical massage therapists and licensed home health workers who provide lymphedema services "incident to" the services of a physician.
It is an unfortunate reality that CMS has for ten years ignored our requests for a change in lymphedema treatment coverage policy. We will continue to pursue every opportunity to achieve change (policy change, statute change, adjudication) and hope that CMS will involve us in their planning to better coordinate these parallel efforts.
We are certain that the coverage of treatment of lymphedema by the well-established protocol of complex decongestive therapy and adjunctive pneumatic compression will save Medicare millions of dollars each year. In our small way, NLN will be helping solve the Medicare viability problem while we help our members.
Robert "Bob" Weiss, M.S.
NLN LE Legislative Advocate