lymphedema why it not covered by medicare

by Lonny Durgan Published 3 years ago Updated 2 years ago

Lymphedema may be considered an "out-of-capitation" or "out-of-network" service. Medicare covers PT/OT visits for medically necessary services. Remember that if you only have Medicare A and B, you will be responsible for 20% of the cost of your treatment. If you have a Medicare supplement, that 20% should be covered.

Full Answer

Is lymphedema therapy covered by Medicare?

Medicare covers the lymphedema pump therapy, but recently the coverage rules have been modified. Previously, although the pneumatic compression devices were included in coverage, the patient had to attempt all other methods of treatment first, a process that took many months. This has changed now.

What if Medicare denies coverage?

Understanding a Medicare denial letter

Reasons for coverage denial. It is beneficial for an individual to understand why they have received a Medicare denial letter. ...
Different types of denial letter. Medicare issues several types of denial letters. ...
Appeals. ...
Levels of appeal. ...
Additional support. ...
Summary. ...

Does Medicare cover lymphedema supplies?

Currently, Medicare, and consequently many other policies, do not cover one of the critical components of lymphedema treatment, the medically necessary doctor-prescribed compression supplies used daily in lymphedema treatment. Learn why…

Is lymphedema treatment covered by insurance?

Untreated lymphedema puts you at risk for serious infections, it is disabling and it is chronic. Unless specifically excluded from your coverage in your insurance contract they must cover lymphedema treatment. There is a medically-accepted protocol for the treatment and management of lymphedema.

Does Medicare cover cost of lymphedema pump?

Medicare covers pneumatic compression devices, commonly called lymphedema pumps, for Medicare beneficiaries afflicted with lymphedema. Lymphedema is a relatively uncommon medical condition characterized by swelling of tissues in an affected body part due to accumulation of excessive fluid.

Will Medicare pay for compression sleeves?

Hard to believe but Medicare does NOT cover most compression garments. Medicare may cover cancer surgery, therapy for lymphedema, and other swelling disorders but when it comes to Medicare covering compression garments, 99% of Medicare recipients will have to pay out of their own pocket.

Is lymphedema surgery covered by insurance?

Lymphedema surgery after cancer treatment is considered a reconstructive procedure and should be covered by health insurance. However, your coverage may only provide a portion of the total fee. Be sure to consult with your insurance company in advance of any surgery.

Is lymphedema considered a chronic illness?

Lymphoedema is a long-term (chronic) condition that causes swelling in the body's tissues. It can affect any part of the body, but usually develops in the arms or legs. It develops when the lymphatic system does not work properly.

Is lymphatic drainage covered by Medicare?

Under current Medicare policy, lymphedema patients have coverage for Manual Lymphatic Drainage (MLD), performed by a qualified Medicare provider such as a physical or occupational therapist, and, when certain conditions are satisfied, a pneumatic compression pump.

How do you bill for lymphedema treatment?

Coding Considerations Medically necessary hands-on MLD is a covered Medicare service and is coded using CPT® 97140 for manual therapy. There is no Medicare coverage for lymphedema compression bandage application as this is considered to be an unskilled service.

What is the life expectancy for someone with lymphedema?

The life expectancy of a patient with this condition is limited to a few months to 2 years [6], [7]. Currently, the mechanism underlying the onset of lymphedema is unknown, and a treatment has yet to be established for preventing the onset of this disease.

Who is a candidate for lymphedema surgery?

You may be a candidate for lymphedema surgery if: You are able to cope well with your diagnosis and treatment. You do not have additional medical conditions or other illnesses that may impair healing. You have a positive outlook and realistic goals for restoring your extremity and body image.

What type of doctor treats the lymphatic system?

Lymphologists are doctors who are specially trained in the diagnosis of and therapy for diseases of the lymphatic system.

Is lymphedema a disability?

You can suffer from a mild case of lymphedema, which is barely noticed, or you can suffer from a debilitating case of it that causes severe pain and makes use of the swollen limb almost impossible. If you have a severe case of lymphedema, you may qualify for monthly benefits for your disability.

What happens if you don't treat lymphedema?

If you don't treat lymphedema it can become dangerous to your health. If swelling becomes unmanageable you'll be more likely to get infections and other complications. Every infection can weaken your immune system and make you more vulnerable to life-threatening illnesses.

What is the difference between lymphedema and lymphoedema?

Key takeaways. Lipoedema is a chronic disorder of fat metabolism and distribution which usually manifests as a disproportional amount of fat stored on the lower half of the body. Lymphedema is an excess build-up of fluid in the arms or lower legs.

What is the Lymphedema Treatment Act?

The Lymphedema Treatment Act (LTA) will improve coverage for the treatment of lymphedema from any cause by amending Medicare statute to allow for coverage of compression supplies. Although this legislation relates specifically to a change in Medicare law, it would set a precedent for Medicaid and private insurers to follow.

Does Medicare cover lymphedema?

What is lymphedema compression?

The lymphedema compression garments are made from elastic materials that vary in stretchiness and are designed to apply different amounts of pressure to body parts. They actually create a pressure gradient, which stimulates the flow of lymphatic fluids to move away from where they generally accumulate in the body.

Does Medicare cover lymphedema compression?

In regards to Medicare coverage for lymphedema compression garments, they do not cover any compression for lymphedema. This includes sleeves, gloves, or any lower extremities. If you have secondary insurance, sometimes it will cover this. The process can be inundating but help is available.

Does insurance cover compression garments?

Insurance Coverage for Compression Garments. Understanding insurance coverage and knowing what is covered and what isn’t can be confusing to say the least. This is especially true when it comes to lymphedema treatment. Some private insurance companies will provide coverage for compression garments while other private payers will not ...

What happens if you leave lymphedema untreated?

Lymphedema is a chronic disease. If left untreated or under-treated, it can lead to infection, disability, disfigurement or death.

What is the treatment for lymphedema?

Treatment for lymphedema will require ongoing care from a physician and a physical or occupational therapist (PT/OT). You will need to purchase supplies to control your swelling. This article provides you with information to use when speaking to your insurance company. Every insurance carrier and plan is different – you should find out ...

How much of Medicare is covered by Medicare Supplement?

Remember that if you only have Medicare A and B, you will be responsible for 20% of the cost of your treatment. If you have a Medicare supplement, that 20% should be covered.

Is lymphedema considered out of network?

Lymphedema is often considered an "out-of-capitation" or "out-of-network" service. You may be allowed to attend any facility with the assistance of your PCP to obtain an 'out-of- network referral' from your insurance company. Medicare covers PT/OT visits with no financial limit on services that are medically necessary.

Can you wear compression at night?

Night-time bandage alternatives: You will need to wear compression at night. You cannot wear your daytime compression garments at night as they will have a tourniquet effect. You can either bandage (using the short-stretch bandages listed above) or purchase a night-time bandage alternative.

Does Medicare pay for compression?

Currently, Medicare does not pay for any type of compression listed below. Other insurances may cover these as "durable medical equipment.". Bandages: Initial and ongoing treatment involves the use of short-stretch bandages.

Who diagnoses lymphedema?

Typically a physiatrist (physical medicine and rehabilitation doctor), primary care physician or oncologist will diagnose your lymphedema. You should form a relationship with a health professional who understands lymphedema and can follow your care long term.

News & Events

It is taking longer than we had hoped to get our bill reintroduced. However, we are anticipating that this session's bill will have added clarity and enhance our ability to attract the broad Congressional support that is necessary, hence making it well worth the wait.

Lymphedema Treatment Act Update

General Information

Article Guidance

We are providing clarification of coverage and documentation requirements for lymphedema decongestive treatment based on Noridian medical review findings.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

Does Medicaid Cover Lymphedema Therapy?

Lymphedema therapy uses different techniques and equipment to reduce swelling in people who have lymphedema, including exercise, manual fluid drainage, compression through bandages and garments and lymphatic pumps.

Is Lymphedema Massage Covered by Medicare?

Medicare coverage for lymphedema therapy is limited. Benefits do include manual lymphatic drainage, which is also known as lymphedema massage. To be covered, it must be performed by a qualified Medicare provider, such as a physical or an occupational therapist.

What Can I Expect at a Lymphedema Clinic?

Lymphedema clinics are specialized medical facilities that diagnose and treat lymphedema. Your first visit to a clinic will involve diagnosing the problem and developing a treatment plan. The therapist will generally ask about:

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