Appeal to Medicare for nonpayment for lymphedema

The reasoning in your physician's letter might be as follows:

  1. Patient has diagnosed medical condition of lymphedema. This is not a symptom requiring symptomatic treatment, but a diagnosed chronic medical condition, ICD-9-CM code 457.0 or 457.1.
  2. If not treated medically, the condition is permanent and progressive, and will degenerate in time. If not treated medically it will also place the patient in significant risk of rapid-onset infection, requiring antibiotic treatment in an emergency setting. And each infection further damages the lymphatic system making subsequent treatment more difficult and expensive.
  3. Current medical standard of treatment of lymphedema is complex decongestive therapy, a multimodal treatment comprising ALL of the followinng modalities: a. MLD b. Compression therapy c. exercise d. skin care.
  4. Compression therapy requires the wearing of bandage systems day and night, bandages or non-elastic compression devices at night with compression garment during the day.
  5. The effectiveness of the therapy is a direct function of patient compliance, and if the patient is not helped to be compliant, treatment will fail.
  6. Since compression garments are worn daily against the skin, they must be laundered every night, thereby necessitating the use of two garments simultaneously. Medical necessity governs the number of garments required, and anything short of 4 garments per year will probably not meet the treatment requirements for lymphedema according to current medical treatment standards.
  7. The expected lifetime of the garments according to the manufacturer is 4-6 months. Daily use of these garments causes loss of elastic properties, and when the garment no longer provides the medically required compression (typically 30-50mmHg) they no longer serve their medical function and must be replaced. At this time the patient is remeasured to assure that the new garment is properly sized to account for the expected reduction in arm size.
  8. Compression garments are not comfort or convenience items which are worn in the absence of a medically diagnosed condition. Rather, they are an essential and integral part of the standard of care for lymphedema, i.e. complex decongestive therapy.
  9. The patient has already had manual lymph drainage by a qualified lymphedema therapist which has brought the diameter of her affected limb down from xxxx cm to yyyy cm. It is medically required for her to be measured and fitted for a compression garment of zzzz mmHg compression in order to maintain the gains achieved by physical therapy.