SOME MEDICARE CLAIMS STATISTICS OF INTEREST TO LYMPHEDEMA PATIENTS

The Office of Medicare Hearings and Appeals (OMHA) makes available the statistics of Level 3 appeals, i.e. those appeals reaching the Administrative Law Judge (ALJ) level. A perusal of these statistics from the point of view of this lymphedema patient advocate confirms my long-held opinion that lymphedema patients are neglecting to assert their rights to obtain reimbursement for their compression bandages and garments. By failing to appeal Medicare’s denial of these medically necessary lymphedema treatment items they are confirming the CMS claim that compression items are not covered, “that there are no insurers who have identified an operational need to revise the HCPCS codes with respect to lymphedema compression garments, and that the existing codes adequately describe the garments available and used in the daily treatment of lymphedema”, and that there is no need to change Medicare policies. In fact, dozens of ALJs have determined they are already covered as prosthetic device benefits under existing statutes.

Statistics on OMHA appeal receipts for the years 2006 through 2014
https://www.hhs.gov/about/agencies/omha/about/health-data-sets/receipts-by-procedure/index.html reveal the following average number of appeals per year for the 9-year period: bandages 419 appeals per year; compression stockings 28 appeals per year; and compression sleeves 3 appeals per year. With so few appeals it is no wonder that CMS believes that there is no problem with the coverage of lymphedema treatment for their millions of beneficiaries suffering from lymphedema. Over the same period over 11,600 compression pumps reached Level 3 appeal.

Have you been denied a compression bandage system, sleeve, or stocking from Medicare? By not filing an appeal of the denial you virtually assure that you will not be reimbursed, and that there will continue to be no pressure on CMS to fix the system for the estimated 1.6 million lymphedema beneficiaries. Medicare-enrolled suppliers are bound by law to file a claim even if they believe that your bandages or garment are not covered. And if they refuse, you are entitled to file the claim yourself. See LymphActivist’s Site at www.lymphactivist.org for information on your rights, how to file an appeal, and the rationale for the assertion that compression materials used in the treatment of lymphedema are covered by Medicare as prosthetic device benefits.

BANDAGES

Conformal Bandages n/s <3” wide 7

Conformal Bandages n/s 3”-5” wide 92

Conformal Bandages n/s >5” wide 4

Conformal Bandages sterile <3” wide 24

Conformal Bandages sterile 3”-5” wide 2,780

Conformal Bandages sterile >5” wide 12

Elastic Compression Bandage 1

Elastic Garment Covering 1

Light Compression Bandages <3”wide 6

Light Compression Bandages 3”-5” wide 823

Light Compression Bandages >5”wide 9

Tubular dressing 41

Tubular Elastic Dressing 2

Non Elastic Extremity Binder 10

Total Number of Bandage Appeals 3,772

Average Bandage Appeals per year 419

STOCKINGS

Compression Stockings 18-30 mmHg 27

Compression Stockings 30-40 mmHg 68

Compression Stockings 40-50 mmHg 21

Gradient Compression Stocking 55

Gradient Compression Stocking Custom Made 31

Gradient Compression Stocking Full Length 40-50 mmHg 1

Gradient Compression Stocking Lymphedema 7

Gradient Compression Stocking Thigh Length 18-30 mmHg 13

Gradient Compression Stocking Thigh Length 30-40 mmHg 15

Gradient Compression Stocking Thigh Length 40-50 mmHg 4

Gradient Compression Stocking Waist Length 18-30 mmHg 6

Gradient Compression Stocking Waist Length 30-40 mmHg 2

Total Number of Compression Stocking Appeals 250

Average Compression Stocking Appeals per year 28

SLEEVES

Custom Gradient Compression Sleeve Heavy 2

Custom Gradient Compression Sleeve Medium 1

Custom Custom Gradient Compression Sleeve/Glove 1

Mastectomy Sleeve 22

Total Compression Sleeve Appeals 26

Average Compression Sleeve Appeals per year 3

Over the same 9-year period 11,627 pneumatic compression pumps were appealed and reached the ALJ Hearing level.

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Lymphedema Treatment is Good Business as well as Good Medicine
© 2002 Robert Weiss, Porter Ranch, CA