Lymph Activist's

LymphActivist's Site

Dedicated to Lymphedema Patients and the Therapists Who Treat Them

LymphActivist's Site

Dedicated to Lymphedema Patients and the Therapists Who Treat Them

INSURANCE & MEDICARE
Lymphedema Treatment Cost Update- Little data exists on the cost, to insurers, of the treatment of lymphedema from all causes. An update has been presented at the 7^th World Congress on Health Economics, Health Policy and Healthcare Management in London which summarizes sixteen years of cost and benefit experience with a lymphedema treatment mandate in the Commonwealth of Virginia. This data updates the 10-year summary published in the Health Economics Review in 2016.
I have been cancelled! My March 25 Insurance Presentation "How Are Compression Bandages, Garments, Devices and Supplies Coverable under the Social Security Act?" was to have been presented as part of NLN's Lymphedema Awareness Month daily lectures, but was withdrawn by NLN at the last moment. The bases for the withdrawal are basically that: the discussion is beyond the 6th grade level of the audience; the dictionary and Medicare statutory definitions are not universally accepted; clinical data should not be a part of an insurance discussion; ICD-9 codes were used instead of ICD-10 codes; and finally, nobody else thought of this approach to the interpretation of Medicare statutes so it must be wrong. It is precisely because my approach is different that I feel it is important to present it as the basis for discussions. CMS has refused for 19 years to hold an open discussion of the concepts presented, which are based on a meticulous analysis of Medicare statutes and policies in light of recent advances in the knowledge of lymphatic function. Read the presentation and make up your own mind.
Better Lymphedema Care results in Medicare Cost Savings–A Proposal. A letter has been sent to heads of key offices of the Department of Health and Human Services (HHS) describing how incorrect implementation of Medicare procedures leads to a waste of resources which CMS steadfastly refuses to address in a professional manner. It also describes a new assault on the rights of Medicare beneficiaries to receive a fair appeal of denials of their compression items–Medicare Stealth Level Appeals.

Medicare Stealth Level Appeals, A recent Medicare appeal case with which I am involved took an interesting turn, illustrating a new and particularly disturbing ploy that CMS is taking to avoid having to reimburse Medicare beneficiaries for reasonable and necessary medical supplies.

No Progress on Formal Request for NCD. As of July 4, 2019, no action has been taken by CMS in response to the formal request for an NCD on coverage of compression garments as prosthetic device benefits.
The American Lymphedema Framework Project (ALFP) is asking for patient, professional, industry partner inputs to help understand the effects of lymphedema treatment, and to set international standards for outcome measures for patients with chronic edema. https://www.surveymonkey.com/r/CYSCKKT This is a great opportunity for lymphedema patients and therapists to get their inputs into new guidelines for lymphedema treatment. See my opinions on this issue http://www.lymphactivist.org/functional_outcomes_measurement1.pdf Thank you for your help.
Lymphedema patients covered by Medicare are neglecting to assert their rights to obtain reimbursement for their compression bandages and garments even though dozens of ALJs have determined they are covered as prosthetic device benefits under existing statutes.
New York State LE Patient Education Bill. New York State Legislature passed its second patient education law, defining who is at risk for lymphedema and mandating the informing of patients at risk of the nature and symptoms of this condition, and where to obtain diagnosis and treatment.
Congratulations to the State of Maryland for passage of the Health Insurance – Coverage for Lymphedema Diagnosis, Evaluation, and Treatment bill . In addition to coverage of compression items used in thetreatment of lymphedema, this bill provides coverage for diagnosis, evaluation and treatment of lymphedema — coverage neglected by the MedicareLymphedema Treatment Act (LTA).
Annual Outpatient Therapy Cap Eliminated. The hard cap on therapy services under Medicare has been eliminated. As part of a bipartisan budget deal passed on February 9, Congress enacted a permanent solution to the problematic hard cap on outpatient therapy services under Medicare Part B, ending a 20-year cycle of patient uncertainty and wasteful short-term fixes.
2018 Medicare Changes. A summary of upcoming Medicare Part-B changes affecting therapy has been provided by Dolores of Montero Therapy Services. Changes affect the therapy cap, therapy exceptions process, manual medical review process, and therapy CPT codes. Thank you Dolores.
CMS Contractors Still Dispensing Incorrect Information to Therapists. The Medicare Part A/B Contractor's educational webinar for outpatient therapists on July 18, 2018 demonstrates that this contractor still does not understand how maintenance therapy for lymphedema patients is covered and does not depend on the patient's potential for improvement from the therapy, and that lymphedema bandaging is a skilled service.
Jimmo Settlement Update. A Federal Judge has determined that CMS failed in their attempts to notify their Administrative Contractors that expected functional improvement is not required as a condition for reimbursement for therapy, and that the Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration. CMS has posted a new educational web site on the Jimmo Settlement.
Making a Medicare or Insurance Claim. My article of the same title from the July-Sep 2011 NLN LymphLink has been updated to reflect new ICD-10-CM diagnostic codes and changes in hot links to CMS web sites. Appeals of denials of compression materials is smoother if the initial claim is "clean".
The Local Coverage Determination and Policy Article for Pneumatic Compression Devices has been extensively revised by CMS since its 2015 issue, mostly to add explanatory information for administrative contractors. The basic medical problems posed by this policy remain, however.
See http://www.lymphactivist.org/ pcd_lcd_updated.php
Compression Garments are covered by Vermont Medicaid. In a well-reasoned update to their medical policy for compression garments in August 2016, the Department of Vermont Health Access outlines the conditions for coverage of compression garments in the treatment of venous insufficiency with severe edema, lymphedema, deep vein thrombosis (DVT) prophylaxis, thrombophlebitis/phlebitis, etc. They are covered by Vermont Medicaid: when medically necessary; as covered prosthetic devices per the Code of Federal Regulations 42 C.F.R. 440.120(c); and with prior authorization.
Lymphedema diagnosis and treatment insurance bills re-introduced in New York State Legislature. Assembly Bill A02271, reintroduced by Assembly Member Rosenthal and Senate Bill S04292 reintroduced by State Senator LaValle, require health insurance policies and contracts to provide coverage for the diagnosis and treatment of lymphedema; and require that such coverage shall include benefits for equipment, supplies, devices, complex decongestive therapy and out-patient self-management training and education for the treatment of lymphedema. The bills also add language to include lymphedema treatment for post-mastectomy patients, in conformance with the Women's Health and Cancer Rights Act of 1998. The bill text and status may be found on the New York State Assembly web site at
http://assembly.state.ny.us/leg/?term=2017&bn=A02271
Lymphedema compression wraps and garments still covered in California by ACA. The California Department of Managed Health Care (Department) has updated its website giving notice of a proposed regulation, Essential Health Benefits, amending Title 28 of the California Code of Regulations. This change updates the existing § 1300.67.005 Essential Health Benefits regulation and maintains the coverage of lymphedema compression bandages and garments for insurance obtained under the Affordable Care Act (the Act).
2017 Annual Update to the Therapy Code List. For CY 2017, the Current Procedural Terminology (CPT) Editorial Panel created eight new codes (97161-97168) to replace the 4-code set (97001-97004) for Physical Therapy (PT) and Occupational Therapy (OT) evaluative procedures. The new CPT code descriptors for PT and OT evaluative procedures include specific components that are required for reporting as well as the corresponding typical face-to-face times for each service.
FORMAL REQUEST MADE BY LYMPHACTIVIST FOR MEDICARE COVERAGE OF LYMPHEDEMA COMPRESSION ITEMS. Based on twenty years of advocacy and over 100 ALJ appeals, I have submitted a formal request to CMS for Medicare coverage of lymphedema compression bandages, garments, devices and supplies as prosthetic device benefits. Personally this is a significant time, since October 2016 will mark 25 years since my wife Pearl was diagnosed and treated for breast cancer and started her lymphedema odyssey.
LYMPHACTIVIST'S COMMENTS TO PROTECT YOUR APPEAL RIGHTS. As the backlog of appeals pending Administrative Law Judge (ALJ) hearings approaches 1 million cases, the Department of Health and Human Services (DHHS) has proposed statutory changes to the appeal system. The major aims of these statutory changes are to reduce the current backlog, and to reduce the number of new appeals reaching the third level of appeal, i.e. the ALJ Hearing. Some of these changes reasonably streamline the appeal process, but others could chip away at current appeal rights of Medicare beneficiaries. LymphActivist has submitted a response to DHHS during the comment period th at just ended , pointing out potential dangers in some of the proposed changes.
Another nail in the lymphedema reimbursement coffin?
The proposed Physician Fee Schedule for 2017 CMS-1654-P contains the latest proposed changes to physical therapist reimbursement rules. It continues to determine reimbursement on the basis of "body structure and function", and could effectively rule out treatment of lymphedema before it becomes disabling. See CALL TO ACTION below.Comments are accepted until September 6, 2016. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html
CALL TO ACTION !!!! IMPACT OF UPCOMING MEDICARE REIMBURSEMENT CHANGES ON LYMPHEDEMA TREATMENT PRACTICE
A letter was written to the Chief Medical Officers of the four DME MACs urging them to change the upcoming revised pneumatic compression device (PCD) local coverage determination (LCD) to better reflect new knowledge of lymphedema and new technologies.
An updated version of the PCD LCD is scheduled to become effective nationwide on December 1, 2015. Major changes in qualification trials, face-to-face encounters and documentation requirements will make it more difficult for lymphedema patients to obtain lymphedema PCDs.
LymphActivist's analysis of the history of PCD LCD changes and comments on the profound impact on lymphedema patient's access to lymphedema pumps.
Comments are solicited for changes to Surgical Dressing Local Coverage Determination (DL33831) and Surgical Dressing Policy Article (A54563 DRAFT). These are the documents cited for denials of compression garments due to a misinterpretation of Medicare statutes.
Response to Senate Finance Committee request for suggestions for improved care for Medicare patients with chronic conditions.
Proposed Local Coverage Determination on Bioimpedance Spectroscopy Devices for Detection and Management of Lymphedema (DL36141) would deny Medicare coverage of L-Dex measurement in ten states. Comments solicited at upcoming open meetings.
Therapy Caps Exceptions Process Extended Through CY 2017-- The therapy caps exceptions process for PT, OT, and SLP services was extended through the remainder of CY 2015, and for all of CY 2016 and CY 2017, when the Medicare Access and CHIP Reauthorization Act was signed into law on April 16, 2015.
CMS announces that use of the -59 Distinct Procedural Services modifier will be allowed after January 1, 2015 along with the new -X[EPSU] modifiers in appropriate circumstances.
2015 CPT® no longer excludes simultaneous multilayer bandaging and MLD. May be billed for same encounter.
Medicare Changes 2014-2015 Relevant to Therapy Services. Presented at the Networking & Educational Seminar for Lymphedema Therapists, Rancho Mirage, CA May 1-3, 2015.
Time for APTA and AOTA to propose quality measures for treatment of lymphedema without functional deficiency or debridable wounds, but for prevention and treatment of the medical condition itself.
Lymphedema Treatment Option Passes in Louisiana — A Step Backward for Lymphedema Patients?
The Affordable Care Act and Lymphedema. California Adds Coverage of Compression Bandages and Garments!
Lymphedema Pump Ordering Policy Modified. Requires Physician or NPP Face-To-Face Meeting. Certificate of Medical Necessity Clarifications.
Medicare Will ReconsiderTherapy Maintenance Care Denials Because of Lack of Functional Improvement 2011-2014. Reconsideration Forms and Instructions Available.
Durable Medical Equipment(DME) Minimum Lifetime Reaffirmed as 3 Years. Grandfathering Clarified.
Medicare Therapy Caps and Exception Process Extended Until March 31, 2014. Annual Cap Raised to $1920 and Manual Review Threshold Remains at $3700.
Manual Updates Issued to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius
CMS Retires Physical Medicine LCD… Casualty of Jimmo? (The Case of the Disappearing Improvement Standard)
Insurance Coverage of Lymphedema Compression Bandages and Garments Starts Jan 1, 2014 in California.
Caution: Home Health Episode Payment Caps
MedPAC Recommendations for Changes to Medicare Outpatient Therapy Services
Medicare urges seniors to join the fight against fraud New health care summaries help seniors identify improper payments
(Non)Coverage of Lymphedema Treatment
Therapy Functional Outcome Reporting at the Lymphedema Seminar
Items Requiring Coding Verification Reviews by the PDAC