Medical Policy
8.01.014 Lymphedema Therapy (Complex Decongestive Therapy)
Original MPC Approval: 08/20/2003
Last Review: 10/29/2007
Last Revision: 10/29/2007 |
 Description
Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swelling, most often in the arm(s) and /or leg(s), and occasionally in other parts of the body. Lymphedema can be subdivided into primary and secondary lymphedema. Primary lymphedema has no recognizable etiology, while secondary lymphedema can develop as the result of surgery, radiation, infection or trauma. Specific surgeries, such as surgeries for melanoma or breast, gynecological, head and neck, prostate, testicular, bladder, or colon cancer, all of which currently require removal of lymph nodes, put patients at risk of developing secondary lymphedema. If the lymph nodes are removed, there is always a risk of developing lymphedema, either immediately post-operatively or weeks, months, even years later.
Depending on the severity of the lymphedema, the treatment plan may consist of various modalities as a part of Complex Decongestive Therapy (CDT). These modalities may include manual lymphatic drainage, bandaging, proper skin care and diet, compression garments (sleeves, stockings), remedial exercises, and/or self-manual lymphatic drainage and bandaging.
Policy
Complex decongestive therapy services are considered medically necessary in the treatment of lymphedema.
Policy Guidelines
Rationale
The Women's Health and Cancer Rights Act of 1998 (Public Law 105-277) required group health plans to provide coverage for services related to mastectomy including prostheses and physical complications related to mastectomy, including lymphedema. Effective 2004, The Virginia General Assembly mandated coverage for lymphedema therapy when prescribed by an authorized health care provider (see Benefit Applications). This policy is in compliance with the requirements of these laws for Members affected by this condition.
Benefit Applications
Lymphedema Therapy benefits are subject to any applicable deductible, coinsurance, copayment or benefit limitation.
When benefits are provided in the member's contract, benefits for Lymphedema Therapy (Complex Decongestive Therapy) are provided for the treatment of lymphedema to include equipment, supplies, therapy, self-management training and education. The following are services related to Lymphedema Therapy:
- Manual lymphedema drainage therapy normally consists of education, skin care, massage, containment wrapping, exercise and supportive garments. Benefits are allowed for physical therapy services associated with this treatment (see Provider Guidelines).
- Services such as education and skin care are considered part of evaluation and management services.
- Pneumatic compression devices (lymphedema pumps) are covered for the treatment of lymphedema when prescribed by a physician, and when they are used with appropriate physician oversight, i.e.:
- physician evaluation of the patient's condition to determine medical necessity of the device;
- assuring suitable instruction in the operation of the machine;
- a treatment plan defining the pressure to be used and the frequency and duration of use; and
- ongoing monitoring of use and response to treatment.
Repairs of lymphedema pumps are limited to restoration to a serviceable condition. Replacement of a Member-owned lymphedema pump and/or sleeve is covered if any of the following criteria are met:
1. When necessitated by irreparable damage not due to misuse, intentional or non-intentional.
2. The cost of repairs to the device and/or sleeve would exceed the purchase price.
Effective January 1, 2004, the Virginia General Assembly has mandated coverage for lymphedema therapy (Annotated Code of Virginia, Sec. 38.2-3418.14) to include benefits for equipment, supplies, complex decongestive therapy, and outpatient self-management training and education for the treatment of lymphedema, if prescribed by a health care professional legally authorized to prescribe or provide such items under the law.
Provider Guidelines
Therapy must be prescribed by a health care professional legally authorized to prescribe or provide such items under the law.
The determination by the physician of the medical necessity of a pneumatic compression device should include (1) the member's diagnosis and prognosis; (2) symptoms and objective findings, including measurements which establish the severity of the condition; (3) the reason the device is required, including the treatments which have been tried and failed; and (4) the clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the member (or caregiver) to apply the device for continued use in the home. This information should be documented in the medical record.
When pneumatic compression devices are ordered in the home setting for the treatment of lymphedema:
- The member should have undergone a four-week trial of conservative therapy and the treating physician determined that there has been no signficant improvement or if significant symptoms remain after the trial. The trial of conservative therapy should include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.
- A non-segmented device (E0650) or segmented device without manual control of the pressure in each chamber (E0651) is generally sufficient to meet the clinical needs of the member. A non-segmented compressor (E0650) with a segmented appliance /sleeve (E0671-E0673) is considered functionally equivalent to a (E0651) compressor with a segmented appliance/sleeve (E0667-E0669).
When a segmented device with manual control of the pressure in each chamber (E0652) is ordered, there should be clear documentation that the member has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671-E0673) or a segmented device without manual control of the pressure in each chamber (E0651).
When reporting for lymphedema pumps (E0650-E0673), separate benefits are allowed for the actual pump and for the appliance (i.e., sleeve) that is put on the affected body part.
Report with HCPCS codes A6543 - A6545, E0650 - E0673, S8420 - S8431. (These items are considered immediate needs)."
Cross References to Related Policies and Procedures
Physical Therapy, Policy # 8.01.001
References
The following were among the resources reviewed and considered in developing this policy. By reviewing and considering the resources, CareFirst does not in any way endorse the contents thereof nor assume any liability or responsibility in connection therewith. The opinions and conclusions of the authors of these resources are their own, and may or may not be in agreement with those of CareFirst.
Annotated code of Virginia, section 38.2-3418.14 (2004). Coverage for Lymphedema
Centers for Medicare and Medicaid Services, National Coverage Determination Manual. CIM 60-16
Department of Health and Human Services, Office of Inspector General (1998). Medicare Allowances for Lymphedema Pumps. OEI-04-97-00130 available on the World Wide Web @ http://www.dhhs.gov/progorg/oei.
National Lymphedema Network (2002), Lymphedema: A Brief Overview. Retrieved from the world wide web at http://www.lymphnet.org/whatis.html
TriCenturion, Local Medical Review Policies, 14.26 Pneumatic Compression Devices (used for Lymphedema) retrieved from the World Wide Web @http://www.tricenturion.com/content/dmerc/0302_14_26_pneumatic_pneumatic_pumps.cfm
Women's Health and Cancer Rights Act of 1998; Public Law: 105-277 (10/21/98). Retrieved from the World Wide Web at http://www.cms.hhs.gov/hipaa/hipaa1/content/hiwhlang.asp
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