Patients receive direct benefit from the new bill. Up to this point, Medicare and other similar policies did not cover doctor-prescribed compression supplies used daily, which are critical components of lymphedema treatment. An estimated 3-5 million Americans suffer from lymphedema, a buildup of lymphatic fluid that can be painful and debilitating. Compression supplies can be costly without insurance assistance, and therefore, many patients suffer from worsening progression of their condition without the supplies needed to maintain it.
Do you have a lymphedema diagnosis from your doctor?
A lymphedema diagnosis and prescription from a licensed clinician is required for benefits coverage. While there are many related diagnoses to lymphedema, such as lipedema, phlebolymphedema, obesity, cellulitis and chronic venous insufficiency, at this time, they are not covered.
Specific ICD-10 codes have recently been specified by CMS. You can find those noted here.
Learn more about lymphedema.
Do you qualify for Medicare?
Medicare is health insurance for people 65 or older. You may be eligible to get Medicare earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease).
Some people get Medicare automatically, others have to actively sign up, but it depends if you start getting retirement or disability benefits from Social Security before you turn 65.
If you don’t qualify for Medicare, there are other types of health insurance plans available:
Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
What products and services are covered under a lymphedema diagnosis?
- Daytime use compression garments – 3 per affected body part every 6 months. This includes ready-to-wear and custom garments, both flat-knit and circular-knit stockings and inelastic wraps.
- Night care garments: 2 nighttime garments every 24 months.
- Bandaging – specific amounts and duration are not yet specified.
As this is a new process, claims filed with the DME MACs (Durable Medical Equipment Medicare Administrative Contractors) will be on a manual review process until all policies are in place which could be well into 2024.