~ Excerpted from the January 2007 Issue of LymphLink
Throughout my correspondences with the Centers for Medicare and Medicaid Services (CMS) over the last six years, I have maintained that the compression items used in treatment of lymphedema (e.g., low-stretch bandage systems, compression garments, directional flow pads and garments, compression devices, etc.) are coverable under the Social Security Act. CMS maintains that there is no benefit category covering these items, and that the law must change to provide coverage. CMS rejects claims for these items as DME because they are not “rentable,” and because they are not used together with a piece of DME such as a pneumatic pump, surgical dressings (since they are not used to secure a primary surgical dressing on a debrided wound) and splints and braces (since they are constructed of flexible fabric).
My legal and medical argument is that these items must be considered according to their medical function and tested against the Social Security Act. When so tested as elements of the compression therapy for lymphedema, they meet all the requirements of §1861(s)(8) Prosthetic Devices. In August 2006 a Medicare Administrative Law Judge (ALJ) made a favorable decision on a four-year long Medicare appeal, in which he found that the directional flow sleeve, custom flat-knit compression sleeve and gauntlets, and bandages met all the statutory requirements for prosthetic devices and supplies, and must be reimbursed. Office visits to a lymphedema therapist for evaluation and garment fitting were also reimbursable. In light of this Medicare ALJ decision a meeting was arranged with staff from the CMS in Baltimore , MD to discuss changes to Medicare national policy adding coverage of lymphedema compression therapy items. Dr. Wade Farrow and I represented the NLN at this meeting
Nine CMS staff members attended, representing the Coverage Analysis Group, Office of Clinical Standards and Quality, Division of Post-Acute Care, Center for Medicare Management, Chronic Care Policy Group, Division of Practitioner Services, and the HCPCS Working Group. Dr. Farrow discussed the anatomy, physiology and pathologies of the lymphatic system and the role of Manual Lymphatic Drainage (MLD) and compression in the treatment of edema and lymphedema. Then, I presented my arguments leading to the ALJ's decision that compression materials used in the treatment of lymphedema meet all the statutory requirements for coverage as prosthetic devices and supplies. I requested that CMS open up the issue of Medicare coverage of the treatment of lymphedema leading to a National Coverage Decision, involving coverage of compression therapy items, physical medical services by trained and qualified lymphedema therapists, and use of sequential compression pumps only as an adjunct to CDT (the primary treatment of lymphedema) in special situations. Walter Rutemueller, Division of Post-Acute Care, closed the meeting promising to take the materials we distributed and discuss the issue with others at CMS before contacting us on any future action.
Following the meeting on prosthetic devices, we met with Cyndy Hake, Director of the HCPCS Working Group, and with Dr. Jim Bowman, Office of Clinical Standards and Quality, to discuss compression item coding. I presented them with a proposed structure for including the various compression items used in lymphedema treatment in the HCPCS listing. The matrix is a working paper and will require coordination with garment and bandage manufacturers to ensure compatibility with their product lines. It starts with existing prosthetic device codes for breast prostheses and lower limb lymphedema compression garments, as well as upper limb lymphedema compression garments and supplies, and adds Torso Compression Garments, Head and Neck Compression Garments, Compression Bandaging Kits and Lymphedema Directional Flow Garments and Pads and related items. The list will be coordinated with manufacturers and submitted as a formal a HCPCS Coding Modification Recommendation to CMS before the January 3, 2007 deadline.
Overall, I believe the meetings were successful. I believe we were able to educate a dozen CMS staffers on lymphedema, the shortcomings of current Medicare policies, and the benefits to be anticipated by changing these policies within the current Social Security Act. Their response will determine exactly how successful we were. I left them with the slogan: LYMPHEDEMA TREATMENT IS GOOD BUSINESS AS WELL AS GOOD MEDICINE.
Carolyn Lucey, a Director of the Circle of Hope Lymphedema Foundation, has led a group dedicated to getting lymphedema legislation on the books in Connecticut . Several members of the group met with State Senator Joseph J. Crisco, Chair of the Insurance and Real Estate Committee in addition to being the Chief Assistant President Pro Tempore, to discuss this condition and legislation that was needed. He has agreed to sponsor the lymphedema compression bill.
The initial proposed bill would provide that “…reimbursement for the costs associated with the diagnosis and treatment of lymphedema. Such reimbursement shall include the cost of medically required compression garments, compression pads, bandages, bandage liners, appropriate skin care products, or special footwear deemed by the patient's certified provider to be medically necessary. Replacements are covered when required to maintain their medically required compressive function or to accommodate changes in the patients' dimensions or medical condition.”