Dedicated to Lymphedema Patients and the Therapists Who Treat Them
YOUR RIGHTS TO INSURANCE COVERAGE OF LYMPHEDEMA TREATMENT
APPROACH TO AN INSURANCE APPEAL IF YOUR CLAIM IS DENIED
(source: Aventis Living With It: A support program for women with recurrent BC through YSC July 2003 Meeting Minutes)
Call your carrier and find out why your claim was turned down for payment. It may be as simple as a claim being input improperly. However, if it is not merely a clerical error and you feel that something should be covered, you have the right to an appeal.
If the matter is not merely a clerical error and you feel that something should be covered, you can appeal the decision. Sometimes all it takes is a simple request to have your claim reviewed over the phone. However if that isn't enough, consider taking the following, more formal steps for an appeal:
Read your policy or benefits booklet to ensure that there's nothing in the plan that specifically excludes the type of care you received or are scheduled to receive.
Write a letter to the insurance company. Usually it should be addressed to the person who signed the letter notifying you that your procedure or treatment would not be covered. Explain why you feel the procedure should be reimbursed and ask that your request be reviewed by a physician with the same specialty as the doctor who ordered the treatment or procedure that's in question. Send a copy of the denial notification you received along with your letter. The letter itself should ask why coverage is being denied or paid at a reduced level. Also, request a copy of the specific statement — drawn from the policy or from the benefits booklet — that explains why your coverage is limited or denied.
If you receive an explanation that "your policy does not cover this procedure," you have the right to see that policy language in writing. Make certain that these policy restrictions were in place when you were originally covered by your contract with the health plan and started paying premiums. If the restrictions were not initially in place, you may have the right to coverage under the insurance laws of your state (see www.healthinsuranceinfo.net for state laws).
You can consider sending a duplicate mailing of your appeal letter to the insurance commissioner of your home state. You can get this contact info from the above-mentioned web site. You should include a brief cover letter explaining the trouble you are having and asking for assistance.
If you feel like you aren't getting anywhere, you might want to ask your insurance company about case management. Almost all national insurance companies have case managers who can act as a liaison between you and your carrier, and help coordinate payments to your various providers. Case managers are professionals and often registered nurses.
(From Manual Lymphedema Drainage Therapy LCD Pennsylvania Highmark Medicare Services LCD Number Y-11C)
The medical record documentation maintained by the provider must clearly document the medical necessity of the services being performed.
WRITE A LETTER OF MEDICAL NECESSITY FOR YOUR DOCTOR TO SIGN
APPROACH TO A MEDICARE APPEAL
The approach I have taken in appealing Medicare denials of lymphedema treatment are to show that: 1) the treatment service or item are medically necessary; 2) is it is part of a medically recommended treatment guideline and is prescribed by the patient's physician; and 3) it falls into a benefit category covered by the Social Security Act.
Specifically, I show that manual lymph drainage (MLD) performed by a specially-trained therapist in accordance with a physician-approved treatment plan determines the frequency and duration of the clinical treatment. The policies on treatment duration established for rehabilitative therapy do not apply to this medical procedure, and that the length of the treatment is determined by medical necessity.
Furthermore, I show that compression bandages, garments and devices fall into the "prosthetic devices" benefit category defined by §1861(s)(8) of the Social Security Act. CMS Publication 100-2, Chapter 15, §120 defines a prosthetic device as follows: "A. General.-- Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered when furnished on a physician's order."
In this case the inoperative or malfunctioning internal body organ is the lymphatic system and the compression items replace all or part of its function.
There are no Medicare coverage determinations or policies dealing with compression bandages, garments or devices when used in the function of treating lymphedema, so Medicare Contractors (and healthcare insurers) select policies which deal with materials which look similar but are used in a different function, and apply the coverage criteria for the other use. They obviously fail and are denied.
Compression bandages are denied for home use because the benefit criteria they are placed into is "surgical dressings", which are non-durable supplies used in an in-patient procedure in conjunction with treatment of an open wound. This is hardly the function of a short-stretch bandage, tubular sleeve or gauze finger bandage in the treatment of lymphedema! My argument is that the assemblage of these diverse materials every night on the lymphedema patient's arm or leg is a prosthetic device which is assembled to the exact medical requirements at that time by a patient or an aide who has been instructed in the specific techniques. It makes no more sense to deny a bandage system because its components are not covered than it would be to deny a wheelchair because its wheels or axle are not separately covered. What matters is the function of this totality of parts in the treatment of lymphedema that determines coverability.
Compression garments are frequently denied either because they "are not medically necessary" or because they do not meet the requirements of "secondary surgical dressings". The first issue is easy to address by showing that these are different from "support stockings" which are worn as comfort or convenience items, not necessarily with physician's prescription. These are required for daily use as part of the medical standard of care of lymphedema. [reference to ISL, ACS, NLN consensus recommendations]
The second argument is more difficult to counter since 2006, when CMS moved the coding of compression stockings from the prosthetic devices category with HCPCS codes Lxxxx to the surgical dressing category with HCPCS codes Axxxx. The criteria for coverage of a compression stocking as a secondary surgical dressing is that it be used with one or more primary dressing in the treatment of an open venous stasis wound. Denied!
So my approach has been to show that compression garments and devices meet the prosthetic device requirements of the SSA, and are therefore not subject to the surgical dressing coverage criteria. So far eleven Medicare Administrative Law Judges have agreed and have ruled that the Medicare patients must be reimbursed for their garments (upper limbs and lower limbs).
The above is solely the opinion of a lay patient advocate, and is not to be interpreted as legal or medical advice. Please consult a properly qualified professional before taking legal or medical action in your specific case.Compiled February 26, 2008.