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In a startling ruling on February 20, 2008 lymphedema compression garments were defined as meeting Medicare definition as a covered item. This will help is obtaining reimbursement for these extremely necessary and important part of a lymphedema management program.
Information on the page provided by lymphedema activist Robert Weiss.
June 21, 2008
Excerpted from the January 2007 Issue of LymphLink
By Robert (Bob) Weiss , MS , LE Legislative Advocate
Throughout my correspondences with the Centers for Medicare and Medicaid Services (CMS) over the last six years, I have maintained that the compression items used in treatment of lymphedema (e.g., low-stretch bandage systems, compression garments, directional flow pads and garments, compression devices, etc.) are coverable under the Social Security Act. CMS maintains that there is no benefit category covering these items, and that the law must change to provide coverage. CMS rejects claims for these items as DME because they are not “rentable,” and because they are not used together with a piece of DME such as a pneumatic pump, surgical dressings (since they are not used to secure a primary surgical dressing on a debrided wound) and splints and braces (since they are constructed of flexible fabric).
My legal and medical argument is that these items must be considered according to their medical function and tested against the Social Security Act. When so tested as elements of the compression therapy for lymphedema, they meet all the requirements of §1861(s)(8) Prosthetic Devices. In August 2006 a Medicare Administrative Law Judge (ALJ) made a favorable decision on a four-year long Medicare appeal, in which he found that the directional flow sleeve, custom flat-knit compression sleeve and gauntlets, and bandages met all the statutory requirements for prosthetic devices and supplies, and must be reimbursed. Office visits to a lymphedema therapist for evaluation and garment fitting were also reimbursable. In light of this Medicare ALJ decision a meeting was arranged with staff from the CMS in Baltimore , MD to discuss changes to Medicare national policy adding coverage of lymphedema compression therapy items. Dr. Wade Farrow and I represented the NLN at this meeting
PROSTHETIC DEVICES MEETING
Nine CMS staff members attended, representing the Coverage Analysis Group, Office of Clinical Standards and Quality, Division of Post-Acute Care, Center for Medicare Management, Chronic Care Policy Group, Division of Practitioner Services, and the HCPCS Working Group. Dr. Farrow discussed the anatomy, physiology and pathologies of the lymphatic system and the role of Manual Lymphatic Drainage (MLD) and compression in the treatment of edema and lymphedema. Then, I presented my arguments leading to the ALJ's decision that compression materials used in the treatment of lymphedema meet all the statutory requirements for coverage as prosthetic devices and supplies. I requested that CMS open up the issue of Medicare coverage of the treatment of lymphedema leading to a National Coverage Decision, involving coverage of compression therapy items, physical medical services by trained and qualified lymphedema therapists, and use of sequential compression pumps only as an adjunct to CDT (the primary treatment of lymphedema) in special situations. Walter Rutemueller, Division of Post-Acute Care, closed the meeting promising to take the materials we distributed and discuss the issue with others at CMS before contacting us on any future action.
Following the meeting on prosthetic devices, we met with Cyndy Hake, Director of the HCPCS Working Group, and with Dr. Jim Bowman, Office of Clinical Standards and Quality, to discuss compression item coding. I presented them with a proposed structure for including the various compression items used in lymphedema treatment in the HCPCS listing. The matrix is a working paper and will require coordination with garment and bandage manufacturers to ensure compatibility with their product lines. It starts with existing prosthetic device codes for breast prostheses and lower limb lymphedema compression garments, as well as upper limb lymphedema compression garments and supplies, and adds Torso Compression Garments, Head and Neck Compression Garments, Compression Bandaging Kits and Lymphedema Directional Flow Garments and Pads and related items. The list will be coordinated with manufacturers and submitted as a formal a HCPCS Coding Modification Recommendation to CMS before the January 3, 2007 deadline.
Overall, I believe the meetings were successful. I believe we were able to educate a dozen CMS staffers on lymphedema, the shortcomings of current Medicare policies, and the benefits to be anticipated by changing these policies within the current Social Security Act. Their response will determine exactly how successful we were.
I left them with the slogan: LYMPHEDEMA TREATMENT IS GOOD BUSINESS AS WELL AS GOOD MEDICINE.
On February 20, 2008, a Medicare Administration Appeals Judge affirmed an earlier Administrative Law Judge's determination that compression garments used as part of the medical treatment of lymphedema meet the definition of “prosthetic devices” in the Social Security Act, and are coverable by Medicare. This is great groundbreaking news. Unfortunately it is not the final solution.
The Good News
This most recent case follows two earlier cases where the Appeals Council reversed two different ALJs who supported providers who denied reimbursement based on the unsubstantiated claim that compression garments “were not covered by Medicare”.
Three other ALJs decided in favor of three different Medicare Beneficiaries, finding that the compression bandages, sleeves, stockings, devices and directional flow garments were medically necessary and coverable in the treatment of lymphedema as “prosthetic devices.”
The Bad News
Unfortunately these cases are not precedent-setting, and there is no desire by the Centers for Medicare and Medicaid Services (CMS) to change their medically unsound policies. CMS has also recently denied a formal request to change their HCPCS Coding manual to recognize the function of these items in the treatment of lymphedema, and to code them as prosthetic devices.
I am prepared to help in all these matters, and have materials which will be helpful.
Robert Weiss, Lymphedema Treatment Advocate Please contact me by e-mail at: LymphActivist@aol.com
This article, written by Robert Weiss, M.S, who is also know as the Lymphedema Patient Advocate will help lymphedema patients with Medicare coverage file a claim for Reimbursement for Compression Garments.
The garment supplier fills out an Advance Beneficiary Notice (ABN) and gives Beneficiary a copy. Beneficiary pays garment fitter and gets a receipt. Make sure that this is the latest version of Form CMS-R-131 which went into effect in March 2008. This is important since the Section (G) Options were in reverse order from earlier versions.
The option to be chosen is the only one which states in bold “I can appeal to Medicare.”
If the Supplier should choose to file the claim for the beneficiary, they will file on a Form 1500. Ask that they fill out Item 27 “Acceptance of Assignment” with a “NO”, and further place the note “Beneficiary refuses to assign benefits” in Item 19. (see note below why Supplier may not be motivated to file for the beneficiary).
The Beneficiary submits to the Centers for Medicare and Medicaid Services (CMS) form 1490 “Patient's Request for Medical Payment to Medicare requesting reimbursement for the garment listed on the ABN, and attaches receipt.” Block 6 Authorization says, ”. . . and request payment of medical insurance benefits to me.” just above beneficiary's signature.
Medicare sends a denial directly to the Beneficiary. This denial appears on the quarterly Medicare Summary Notice (MSN). After the headers on this form, the sentence “This is a summary of claims processed from . . . to . . .” Following this there should be a section labeled “Part B Medical Insurance-Unassigned Claims.” In the last column “See Notes Section” there will be a series of code letters denoting the reason for the denial. There will also be detailed instructions for appealing the decision. There is a 120-day appeal period after which no appeal will be allowed.
If help is needed, the beneficiary may consult Bob Weiss by e-mail at LymphActivist@aol.com to proceed further. At this point he will either guide the beneficiary in the first appeal, or he will file it on behalf of the beneficiary. Several more denials will come down the pike before it goes to an administrative law judge. To begin the appeal Mr. Weiss will need a copy of the Medicare Summary Notice (MSN) that covers this claim.
This first appeal to an independent Medicare Contractor is called a “Redetermination.” The next appeal to a “Medicare Quality Independent Contractor” or a “DME MAC” is a “Reconsideration.” The next appeal is to an Administrative Law Judge (ALJ). None of these appeals costs any more than the cost of making copies and postage. There is a 60-80% chance of a favorable determination by the ALJ. In the event that the ALJ renders an unfavorable decision then the next appeal is to the Medicare Appeals Council (MAC), my success rate here is about a 50% favorable rate.
If the Beneficiary gets reimbursed after 2 years or so, the ABN states that, “If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.” This puzzles me. Does this mean that Medicare will reimburse the garment fitter directly? According to Bob, “That's crazy because it is definitely not in a garment fitter's interest to go to the trouble of submitting an ABN for a Beneficiary only to have to refund their money at a later time.” You are correct that the Supplier has little incentive to file your complaint. The supplier receives a reduced amount of reimbursement from the retail price of the item, and if they are a Medicare Supplier, they are required to file a claim for something they know will be denied. So they will ask for payment in advance. So as long as they are filing on behalf of the beneficiary it is important for the beneficiary to refuse to assign benefits on the Form 1500. That way there will be no refunds necessary.”
Compression Garment Group Health Clinical Review Criteria