Since the Lymphedema Treatment Act took effect, Medicare covers compression garments and supplies for lymphedema, and many commercial and Medicaid plans follow similar rules. Coverage depends on the paperwork. The Lymphedema Advocacy Group (LAG) and the Lymphedema Education & Awareness Project (LEAP) publish a provider handout on exactly this; here is a summary, plus how we can help.
Coverage requirements
Diagnosis code: Q82.0 (hereditary lymphedema), I89.0 (lymphedema, not elsewhere classified), I97.2 (postmastectomy lymphedema syndrome) or I97.89 (other postprocedural complications of the circulatory system)
A prescription for each item
Clinical notes that state the lymphedema stage and, for custom garments, why a standard-fit garment isn't appropriate
What's covered, and how often
Daytime garments, custom or standard-fit: 3 per affected body part every 6 months
Nighttime garments, custom or standard-fit: 2 per affected body part every 2 years
Gradient compression wraps with adjustable straps
Bandaging supplies for initial and ongoing treatment: no set limit
Accessories (liners, padding, zippers, donning and doffing aids): case by case
HCPCS codes and allowables are in the CMS DMEPOS Fee Schedule. Medicare's coverage page: go.cms.gov/48PxTKf.
Diagnosing lymphedema
Insurers require a lymphedema diagnosis before covering compression. According to the handout, lymphedema can be diagnosed about 90% of the time from risk factors and a physical exam, and imaging is usually not needed.
What the prescription and notes must show
On the prescription: body part, garment type, compression level if applicable, and standard-fit or custom-fit, in terms that match the new codes.
In the chart: medical necessity for each garment. Describe the lymphedema by body part with stage or severity, then the garment type needed for that part. The diagnosis code must appear in the prescriber's notes, not only on the prescription.
Insufficient vs. sufficient notes
Custom day and night garments for the legs
Too vague: "Bilateral lower extremity garments needed for lymphedema maintenance."
Better: names the type and severity (for example severe, bilateral, primary lymphedema); specifies custom flat-knit, closed-toe, thigh-high daytime garments for each leg; explains why custom fit is needed (abnormal, disproportionate limb shape that a standard garment can't fit with correct gradient); orders 3 per leg for wash and wear; and adds custom nighttime garments, toes to upper thigh, 2 per leg, to soften fibrotic tissue and prevent swelling from building up overnight.
Standard-fit daytime garment for one arm
Too vague: "Unilateral upper extremity compression garments required."
Better: states mild, left upper extremity lymphedema secondary to tumor resection with the year; notes it extends from the fingers to the axilla; orders a standard-fit circular-knit sleeve and a separate glove; and specifies 3 of each for wash and wear.
How Midwest Compression helps
We check orders and let you know if notes are missing the stage, the custom-fit rationale or the diagnosis code.
Our certified fitters measure for standard and custom garments, or use your CLT's measurements on our measurement forms.
We track each patient's 6-month and 2-year replacement dates.
Refer by calling (800) 883-1549, texting (517) 657-5223, using our referral form, or ordering on Parachute Health.
More from the Lymphedema Advocacy Group: LAG keeps free provider and patient resources on coverage, diagnosis and appeals at LymphedemaAdvocacyGroup.org and LymphedemaProject.org.
Source: "Provider Information: Insurance Coverage for Lymphedema Compression Garments and Supplies," Lymphedema Advocacy Group and Lymphedema Education & Awareness Project. Not legal or billing advice.
