International Journal of Physical Medicine & Rehabilitation
Open Access
ISSN: 2329-9096
+44 1300 500008
ISSN: 2329-9096
+44 1300 500008
Robert Weiss
Scientific Tracks Abstracts: Int J Phys Med Rehabil
Background: The currently accepted treatment of lymphedema is ??complete/complex decongestive therapy?. The key protocol for lymphedema treatment in the clinical as well as in home settings is compression. Yet Medicare currently does not reimburse the provider or the patient for the materials required to achieve compression in the treatment of lymphedema. Methods: The current medical treatment protocols for lymphedema are described. The essential role of compression in the medical treatment of lymphedema is highlighted. A summary of the criteria for coverage under the Medicare Program centering on the concept of ??covered benefit categories? is introduced for the purpose of demonstrating that the denial of claims for the compression bandage systems, compression garments, devices and supplies is not based on Medicare law, statute or policy, and that there is a basis for coverage of these items when they are used in the customary medical treatment of diagnosed lymphedema. The Medicare Benefit Coverage Manual, CMS Publication 100-02, Chapter 15, §120 states that ??Prosthetic devices which 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.? This definition of prosthetic device is parsed and excerpts from medical journals used to show how lymphedema treatment articles meet the definition. Results: This argument has been the core of denial appeals since 2004. On August 16, 2006 a U.S. Administrative Law Judge (ALJ) found that compression bandaging materials, a directional flow sleeve, compression arm sleeve and gauntlets received by a Medicare beneficiary for the treatment of his lymphedema ??were reasonable and necessary for reimbursement as a prosthetic device?. Since that initial ALJ determination dozens of ALJs have confirmed that compression items, when used in the compression therapy of lymphedema, meet the statutory definition of ??prosthetic devices? and are covered by Medicare. Conclusions: Acceptance by ALJs of the idea that compression items used in the treatment of lymphedema are coverable as prosthetic devices, based on principles of law and on current medical knowledge of the treatment of lymphedema, gives hope that we can achieve a major upgrade to Medicare coverage of lymphedema treatment without change to existing law, but with new C.M.S. policies based on a fresh interpretation of existing law.
Robert Weiss is a retired aerospace systems engineer with a Master of Science degree from the University of California at Los Angeles. He has completed 80 hours of Dr. Vodder lymphedema therapy training, and is a graduate of the NLN LSAP Program, NBCC Project LEAD and Quality Care LEAD. He has co-authored a systematic review of manual therapy for breast cancer-related lymphedema for the Cochrane Collaboration. He is a member of the ALFP Steering Committee, is a PCORI Merit Reviewer and lectures at lymphedema conferences on incidence and prevalence of lymphedema, breast lymphedema, cost-efficacy of lymphedema treatment, and lymphedema insurance, reimbursement and legislation.