Getting Medicare to recognize lymphedema therapy as an essential medical expense has been a difficult task. Lymphedema patients have long sought the Medicare benefit for the costs they incur for therapy that continues throughout their lives. The Women’s Health and Cancer Rights Act requires all insurance companies to cover complications from breast cancer surgery, including lymphedema. However, this coverage does not extend to those with primary or secondary lymphedema. In February 2008, compression garments considered an essential part of lymphedema therapy were classified as Medicare-covered items.
Lymphedema is a condition that has no medical cure, although it can be controlled with therapy known as Complete Decongestive Therapy or CDT. The process involves lymphatic massage combined with the use of compression bandages and compression garments, a skin care routine, and a regular exercise regimen. The most important aspect of therapy is manual lymphatic drainage (MLD) which aims to drain stagnant lymph to reduce swelling. Occasionally, the therapist may use the sequential gradient pump to loosen fibrotic tissues prior to massage. The therapist who performs lymphatic massage is a specialized professional trained in the technique. Therapy sessions in the early stages can be done frequently, at least five days a week. Those who do not have easy access to a lymphedema therapist can use a sequential gradient pump for the lymphatic drainage process.
Medicare covers pump therapy for lymphedema, but the coverage rules recently changed. Previously, although pneumatic compression devices were covered, the patient had to try all other treatment methods first, a process that took many months. This has changed now. Compression devices have been included in durable medical expenses for primary and secondary lymphedema. There is a four week trial period that the doctor must observe. The patient follows a course of medication, use of compression garments, and elevation of the extremity, and if no improvement is noted, the physician prescribes a pneumatic pump. The physician is required to provide a Certificate of Medical Necessity to allow the patient to purchase a lymphedema pump from a Medicare authorized supplier. The pump supplier must be enrolled in Medicare and have a Medicare supplier number or the claim will not be reimbursed.
In the case of compression garments, which can be a large recurring expense, people with lymphedema have had to deal with legislation that prevented them from being included in Medicare coverage lists. A positive trial in February 2008 has come to the aid of lymphedema patients. Compression garments were classified as items that met the standards for covered items. Items such as compression bandages, compression sleeves, and stockings were considered medically essential and would be covered as prosthetic devices by Medicare for the treatment of lymphedema. Lymphedema patients can take advantage of this edict and claim compensation for these medically essential items that help them manage their lymphedema.