~ Excerpted from the October 2006 Issue of LymphLink
Medicare does not cover the materials used in lymphedema treatment. In March 2006 CMS re-coded the compression garments that are the mainstay of lymphedema treatment from "prosthetics" (the benefit category covering compression garments for lymphedema) to "surgical bandages" (a benefit category which is not covered in a home setting or without an open wound). This effectively denies the millions of lymphedema Medicare beneficiaries coverage of the treatment which they require every day for the rest of their lives. The change was made without prior notice and without any chance for public or expert testimony. It is consistent with the CMS interpretation of title XVIII of the Social Security Act (SSA) that looks at the "form" of the item and not its "function" in determining the benefit category despite the fact that the SSA defines benefits in functional terms.
Section 2130 of the Medicare Contractors Manual defines "Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered when furnished on a physician's order." It is my contention that the lymphatic system constitutes an "internal body organ system" and that compression therapy replaces part of the function of this malfunctioning internal body organ.
Over the last decade, until this year, Medicare has listed the individual components of the bandaging systems as primary surgical dressings (HCPCS Code Axxxx), and the compression garments as prosthetics (HCPCS Code Lxxxx or Sxxxx). Listing, however, does not confer coverage, and Medicare has not covered these items for home use in the treatment of lymphedema. This year CMS has redefined the group of PROSTHETICS, Elastic Supports, and Gradient Compression Stockings L8100-L8239 as SURGICAL DRESSINGS, SECONDARY A6530-A6549. Furthermore, they have eliminated the group of PROSTHETICS, Gradient Pressure Aid (sleeves, gloves and gauntlets) S8420-S8429, Padding for Compression Bandage S8430 and Compression Bandage S8431 from the list of defined PROSTHETICS.
The result of this change in definition of the benefits category of the medical items used in the treatment of lymphedema is to completely eliminate them as prosthetics, which they ARE when one looks at their medical FUNCTION in the treatment of lymphedema, and defines them as secondary dressings which are not covered in a home setting and which must be used to secure a primary dressing in the treatment of an open wound.
I have been assisting Medicare beneficiaries in appeals of their denials of lymphedema treatment materials. My legal and medical arguments, supported by references to medical sources as well as relevant Medicare laws and policies, made the case that compression therapy materials (specifically: compression bandaging systems; compression garments; directional flow pads and garments; non-elastic compression devices) are reasonable and medically necessary in the treatment of lymphedema according to current medical standards. Furthermore, they meet all of the statutory requirements of prosthetics according to Section 1861(s)(8) of title XVIII of the SSA and should not be denied because "they do not fit any statutory benefit category."
On August 16, 2006 a U.S. Administrative Law Judge in Southern California found that certain items received by a Medicare beneficiary for the treatment of lymphedema "were reasonable and necessary for reimbursement as a prosthetic device" and that "payment is to be made on the beneficiary's behalf for the reasonable and necessary medical services rendered and billed." The items included compression bandaging materials, a directional flow sleeve, compression arm sleeve and gauntlets. Visits to a lymphedema treatment center for the purposes of evaluation and measurement and fitting of the sleeves and gauntlets were also allowed.
This decision is applicable only to the single case heard, and does not change Medicare policy or set precedent in other cases. But it is encouraging in that the decision of this Judge was based on principles of law and on current medical knowledge of the treatment of lymphedema, and gives hope that we can get the attention of CMS and upgrade their coverage of lymphedema treatment without any legislative change in the law, but with new policies based on a fresh interpretation of the existing law.
Robert (Bob) Weiss is not a formally trained or qualified physician or lawyer. The foregoing account is his personal opinion and should not be taken as legal or medical advice, nor does it necessarily reflect the opinions of the NLN Board of Directors. It certainly does not represent the opinions of CMS. Bob can be LymphActivist@aol.com