Lymphedema - Medicare News (Not Good)

URGENT ADVOCATE ALERT: Trends in Risk Reduction Practices for the Prevention of Lymphedema * *
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Lymphedema - Medicare News (Not Good)

Postby patoco » Fri Nov 09, 2007 12:14 am

Lymphedema - Medicare News (Not Good)

My proposal to CMS to add over 150 new and revised codes to the HCPCS
Codebook for lymphedema treatment supplies was just rejected again by the CMS
HCPCS Workgroup in Baltimore. This was very depressing because they never referred to
my legal and medical arguments--only stated that "no insurer (i.e. Medicare,
Medicaid, Private Insurance Sector) identified a national program operating
need to establish unique codes to distinguish all the products listed in this
application. Existing codes adequately describe the array of products
available."

This reiterates my feeling that I have not gotten the required support from
providers, suppliers, patients, manufacturers to convince "Medicare, Medicaid
and the Private Insurance Sector" that there could be a "program operating
need", and that there is a proposed solution to the problem which has a rational
legal and medical basis. My record with Medicare Administrative Law Judges
recently, since developing my "prosthetic devices" argument, is 4 favorable, 1
unfavorable decisions. Two cases have been appealed to the Medicare Appeals
Council in Washington. My argument, in brief, is that compression bandages,
garment and devices meet the definition in the Social Security Act of "prosthetic
devices" when used in the standard treatment of lymphedema, and are covered by
Medicare. They are usually denied because they do not meet the policies on
surgical dressings benefit category, which is not their medical use or their
benefit category.

I am in the process of preparing a formal request for a national coverage
analysis on the coverage of the treatment of lymphedema that would lead to a new
national coverage determination and policy, but progress is slow. I am also
preparing a formal request to SADMERC for a reclassification of compression
sleeves and bandages from uncovered S-codes to covered L-codes, and of
compression stockings used in treatment of lymphedema from uncovered A-codes to covered
L-codes. The request is also to add codes for other compression garments which
are not currently described.

Another important reason for reclassifying compression garments from A-codes
(Secondary surgical dressings) to L-codes (prosthetic devices) is that the
specifications for elastic compression garments are different for the two
functions, and the costs can be different. For example, an off-the-shelf elastic
compression stocking used to hold a primary dressing on a venous ulcer (A-code)
is
reimbursed at $43.27. A custom flat-knit stocking used in the treatment of
a lymphatic leg (L-code) has far more stringint technical specifications and
costs far more than the circular-knit elastic stocking to manufacture.
Differences in use, medical requirements, manufacturing costs, etc warrant two
different code groups.

I hope that I can get more support from patients, providers, suppliers and
manufacturers this coming year in my efforts to get CMS to change their
lymphedema treatment coverage policies. Only by appealing every denial of
medical treatment for lymphedema can we impress on CMS that there IS a program operating
need for new coverage policies and codes. Denials are based on non-relevant
policies, HCPCS codes are being used incorrectly, and there are inadequate codes
for the medically necessary coverable items used every day by lymphedema
patients.

And if CMS does not chose to understand the issue, and in the absence of a
lymphedema lobby, we must rely on legislators' constituents (that means YOU) to
create the awareness of a need for legislative change.

Robert Weiss, M.S.
Lymphedema Treatment Advocate
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