Compression Garments Meet Medicare Definition

Introduction

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.

Your Role in Moving CMS to Take Action

• Every denial of compression bandages or compression garments must be appealed by the patient. The procedures for appeal are found in the denial letter.
• The appeal process will involve a redetermination appeal and a reconsideration appeal to Medicare Administrative Contractors, who will side with the denial, and then to an Administrative Law Judge where a fair hearing can be obtained.
• Every lymphedema supply manufacturer must make a formal request to CMS for a recoding of their products with an “L-Code” as prosthetic devices when used in the treatment of lymphedema.
• Every affected citizen, whether suffering from, or at risk for, lymphedema must write his of her Congress Member requesting that CMS revise their policies to cover the treatment of lymphedema according to current standards.
• Since CMS has refused repeatedly to even consider a change, urge your legislator to consider sponsoring the proposed “Lymphedema Diagnosis and Treatment Cost-Saving Act” which has been presented to legislators over the last 5 years.

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Category: Insurance and Medicare Updated: 2008-02-23