Lymph Activist's

LymphActivist's Site

Dedicated to Lymphedema Patients and the Therapists Who Treat Them

APPROACH TO A MEDICARE APPEAL

The approach I have taken in appealing Medicare denials of lymphedema treatment are to show that:
the treatment service or item are medically necessary;
is it is part of a medically recommended treatment guideline and is prescribed by the patient's physician; and
it falls into a benefit category covered by the Social Security Act.

Specifically, I show that manual lymph drainage (MLD) performed by a specially-trained therapist in accordance with a physician-approved treatment plan determines the frequency and duration of the clinical treatment. The policies on treatment duration established for rehabilitative therapy do not apply to this medical procedure, and that the length of the treatment is determined by medical necessity.

Furthermore, I show that compression bandages, garments and devices fall into the "prosthetic devices" benefit category defined by §1861(s)(8) of the Social Security Act. CMS Publication 100-2, Chapter 15, §120 defines a prosthetic device as follows: "A. General.-- 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."

In this case the inoperative or malfunctioning internal body organ is the lymphatic system and the compression items replace all or part of its function.

There are no Medicare coverage determinations or policies dealing with compression bandages, garments or devices when used in the function of treating lymphedema, so Medicare Contractors (and healthcare insurers) select policies which deal with materials which look similar but are used in a different function, and apply the coverage criteria for the other use. They obviously fail and are denied.

Compression bandages are denied for home use because the benefit criteria they are placed into is "surgical dressings", which are non-durable supplies used in an in-patient procedure in conjunction with treatment of an open wound. This is hardly the function of a short-stretch bandage, tubular sleeve or gauze finger bandage in the treatment of lymphedema! My argument is that the assemblage of these diverse materials every night on the lymphedema patient's arm or leg is a prosthetic device which is assembled to the exact medical requirements at that time by a patient or an aide who has been instructed in the specific techniques. It makes no more sense to deny a bandage system because its components are not covered than it would be to deny a wheelchair because its wheels or axle are not separately covered. What matters is the function of this totality of parts in the treatment of lymphedema that determines coverability.

Compression garments are frequently denied either because they "are not medically necessary" or because they do not meet the requirements of "secondary surgical dressings". The first issue is easy to address by showing that these are different from "support stockings" which are worn as comfort or convenience items, not necessarily with physician's prescription. These are required for daily use as part of the medical standard of care of lymphedema. [reference to ISL, ACS, NLN consensus recommendations]

The second argument is more difficult to counter since 2006, when CMS moved the coding of compression stockings from the prosthetic devices category with HCPCS codes Lxxxx to the surgical dressing category with HCPCS codes Axxxx. The criteria for coverage of a compression stocking as a secondary surgical dressing is that it be used with one or more primary dressing in the treatment of an open venous stasis wound. Denied!

So my approach has been to show that compression garments and devices meet the prosthetic device requirements of the SSA, and are therefore not subject to the surgical dressing coverage criteria. So far eleven Medicare Administrative Law Judges have agreed and have ruled that the Medicare patients must be reimbursed for their garments (upper limbs and lower limbs).

The above is solely the opinion of a lay patient advocate, and is not to be interpreted as legal or medical advice. Please consult a properly qualified professional before taking legal or medical action in your specific case.

Compiled February 26, 2008.
Revised December 3, 2009.
Revised April 14, 2010.