Saturday, November 10, 2007

Lymphedema - Medicare News (Not Good)

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 operatingneed 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, 1unfavorable 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-relevantpolicies, 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