what pumps are covered?

[JackieDoss]

I was SO excited that my insurance company said they would pay 100% for a lymphedema pump when FlexiTouch inquired about it. ... but when they got the claim, they denied it. They said that "there was not enough data to validate the superiority of the programmable pump over the non-programmable pump."

The Flexitouch seems to be a PERFECT solution. My question is... What exactly does "programmable" refer to? What pumps are NOT programmable? And are they any good?

[Ann]

Those with lymphedema are fortunate to have Bob Weiss as a knowledgeable, and willing, insurance advocate. For help with your pump issue, you can reach him by e-mail at LymphActivist@aol.com

Good luck!

[LymphActivist]

I was SO excited that my insurance company said they would pay 100% for a lymphedema pump when FlexiTouch inquired about it. ... but when they got the claim, they denied it. They said that "there was not enough data to validate the superiority of the programmable pump over the non-programmable pump."

The Flexitouch seems to be a PERFECT solution. My question is... What exactly does "programmable" refer to? What pumps are NOT programmable? And are they any good?

Jackie:

The answer to your question is very complex. Before trying to make some sense of the "pump" situation I would like to talk about the history of Medicare reimbursement for pumps, because that is the background of all insurance company reimbursement policy.

The original pumps were single-chamber pumps which just applied a constant pressure on the entire limb with an inflatable single chamber sleeve. They were found to be beneficial for edema due to venous insufficiency, where the swelling was caused by an inability of the venous system to remove fluid from the limb. By increasing the tissue pressure over the entire limb, the fluid was forced back into the veins and returned to the heart.

Then someone found that by constructing a sleeve with more than one chamber, and adjusting the pressure at the ankle to be greater than the pressure at the thigh, a graduated tissue pressure was more effective. Again, this was effective for edema caused by venous insufficiency. This still only requred one simple pump and a multi-segment sleeve.

The next development addressed edema caused by a problem in the lymphatic system, and used a multi-chambered pump attached to a multi-segmented sleeve which allowed the pressure to be graduated and sequentially applied from the toes to the thigh.These allowed the specific pressure applied to the leg to be tailored to the specific problem, and also provided some "working" action on fibrotic areas.

Recognizing that the lymphatic fluid was just being "dumped" into the tissue just outside of the sleeve, some manufacturers developed body garments which would drain the torso in preparation for treatment of the limb.

With each advance, the pumps and garments became more complex and more expensive as they became more effective. Medicare and insurance companies have taken the desire to pay for only the minimum effective version of the pump and turned it into a policy which demands that the cheapest pump be used and found to be either ineffective or harmful. Then they will authorize the medically appropriate more expensive pump.

Find a doctor who understands this, does a differential diagnosis of your particular swelling (venous? lymphatic? combined? stage? co-conditions?) and prescribes the appropriate pump for your condition. Stage 1 and early stage 2 lymphedema will probably benefit from MLD and compression garments, and possibly a sequential graduated pneumatic pump. Stage 3 lymphedema and lymphaticovenous edema, where the lymphatics are no longer functional or the edema is due to venous insufficiency might do better with a cheaper graduated compression, non-sequential or sequential pump.

Contact the Flexitouch people. They can amplify on what I have just told you.

As far as evidence goes, I suggest that you tell your insurance company that at a meeting on November 18, 2009 of the Medicare Evidence Development Coverage Advisory Committee (MEDCAC) determined that there is moderate confidence that the evidence DOES SUPPORT the use of programmable pneumatic pumps independently or as an adjunct to CDT in the treatment of lymphedema.

I suggest that you request a letter of medical necessity from your physician based on your medical need and specifically specifying the pump needed for your condition, and then request an Independent Medical Review of your case.

LymphActivist

[nancycels]

I'm looking into a Flexitouch and wondered which insurance company you had a problem with? I'm hoping it's not mine!!! Thanks.

I was SO excited that my insurance company said they would pay 100% for a lymphedema pump when FlexiTouch inquired about it. ... but when they got the claim, they denied it. They said that "there was not enough data to validate the superiority of the programmable pump over the non-programmable pump."

The Flexitouch seems to be a PERFECT solution. My question is... What exactly does "programmable" refer to? What pumps are NOT programmable? And are they any good?

[Ann]

Try reading the article "The History of Pumps" by Bob Weiss "The Lymphedema Activist." There is a link to this article at the bottom of the Lymph Notes home page.

Bob is very knowledgeable on such matters and very willing to help.

Ann:)

[AbsoluteMedical]

Jackie/Nancy,

My name is Joe Rapine from Absolute Medical. We specialize much like Bob does in the treatment of LE with a vast array of products. I am new to the forum and hope that some of the experiences that I have gone through in regards of fitting proper garments to suite people's lifestyles and activities as well as the insurance reimbursement can assist the members in getting what they need to maintain.

In regards to your specific claim with your insurance company it depends if they follow Medicare's guidelines. As Bob was saying previously in his well written post if they do follow the Medicare guidelines there is a trial of lesser intensive remedies prior to necessitating an upgrade to a programmable (calibrated gradient pressure) pump.

Medicare and insurance companies that follow their policies require a 4 week minimum trial with an E0650 (single outlet compressor where the one hose splits into multi cells up the leg but all pump simultaneously ) with a segmented cell leg appliance OR an E0651 (multi-outlet pump without calibrated pressure) with segmented cell or groups of cells where each chamber in the leg sleeve has its own independent hose and pumps in sequentially in order starting at the foot chamber and after each chamber fills to desired pressure moves up the leg towards the groin.

Now all pumps are the same regardless of what level in regards to the fact that you can set the foot pressure at a certain pressure setting. The thing that differentiates the Flexitouch and Lympha press 201m and Optimal from the previously mentioned "in the insurance companies eyes" is that those machines can adjust or "calibrate/program" the more proximal (later cells after the foot) pressures to a lower desired custom pressure. The advantage of this is mostly for comfort as well as not to overload the lymphatics with too much volume of lymph. The lower grade models are either set from the factory to decrease as they go up the leg or they rely on La Place's law which basically says as the circumference in a leg increase over a larger surface area (ie. ankle compared to a thigh) the wall pressure of a vessel decreases. So basically as the cells become larger in the leg appliance it will actually exert less pressure on the limb.

So we now come back to the fact that for most insurance companies you have to trial a lower level pump prior to qualifying for an upcode. Flexitouch does not manufacture a E0650 or a E0651 device. Lyphapress on the other hand(parent company Mego-Afek) have been around for 30 years worldwide does have an entry level piece of equipment which is the Petite Basic System. This is regarded in my opinion as the highest quality Entry level device on the market.

As of January 2009 Medicare basically halted all reimbursements for the higher end E0652 code due to the fact of up coding abuse and basically because the number of providers that were billing the upcode without ever properly trialing a lesser device. I am not sure exactly what trial methods Flexitouch used for their lesser trials or what actual pump that they used to do this since they do not have an E0650 or E0651 one of their own to trial with.

If I could urge you to do some research on Lymphapress Optimal system in comparison to Flexitouch because I think that there are many added benefits that the optimal brings to the table that the Flexitouch does not. If you would like I could post or email you a copy of a side by side comparison as to the features of both to give you real details of how each operates and works. If this comparison does not raise enough eyebrows I guarantee the price difference will. I have included this link to the comparison for convenience. http://www.absolutemedical.net/medicalProfessionals/flexitouchLPO.aspx

If you would like to contact me for further information on these products I would be more than happy to help you out in any way.

Sincerely,

Joe Rapine
Absolute Medical Inc.

[LymphActivist]

Joe Rapine, in his response to Jackie and Nancy makes comparisons between the sequential pneumatic compression devices of two companies. I will leave it to the representatives of the two companies to evaluate the accuracy of these comparisons. I do wish comment on the use of only device comparisons (specifications and cost) to make a selection of the proper device to treat a specific patient's swelling.

First, I hope that Joe does not believe that the Medicare requirement to try a cheaper non-calibratable device before getting an appropriate calibrated sequential device implies that the same manufacturer must have provided both units. That is not the meaning of that requirement. The fact that Tactile Systems does not have a single chamber non calibratable device for treatment of venous insufficiency has no relevance to the issue of selecting an appropriate device to treat the patient's lymphedema--unless the patient also has a venous problem. Again, I refer to my previous advice that a qualified physician who has done a differential diagnosis of the swollen limb should make the recommendation for an appropriate device. This is not a decision that can be made solely by comparing device characteristics and price.


Find a doctor who understands this, does a differential diagnosis of your particular swelling (venous? lymphatic? combined? stage? co-conditions?) and prescribes the appropriate pump for your condition. Stage 1 and early stage 2 lymphedema will probably benefit from MLD and compression garments, and possibly a sequential graduated pneumatic pump. Stage 3 lymphedema and lymphaticovenous edema, where the lymphatics are no longer functional or the edema is due to venous insufficiency might do better with a cheaper graduated compression, non-sequential or sequential pump.

LymphActivist[/QUOTE]

In the words of Medicare DME MAC A:

"The Local Coverage Determination (LCD) for Pneumatic Compression Devices (L11503) states in part:

Pneumatic Compression Devices are only covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers, prescribed by a physician and determination by the physician of the medical necessity which must include the following:
• The patient’s diagnosis and prognosis;
• Symptoms and objective findings, including measurements which establish the severity of the condition;
• The reason the device is required, including the treatments which have been tried and failed; and
• The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters and ability of the patient (or caregivers) to apply the device for continued use in the home."

In my opinion, the 54% E0652 denial and/or downcoding rate observed in a recent DME MAC A 6-month claims audit indicates that the medical documentation submitted with the claims failed to establish the appropriate device for the patient's medical condition--not that cheaper devices are always appropriate for treating swelling.

The Pneumatic Compression Devices (L11503) LCD further states:

“When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation of medical necessity in the individual case. Full payment for code E0652 will be made only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671 - E0673) or a segmented device without manual control of the pressure chamber (E0651).”

Note that the referring physician has the responsibility of selecting the medically appropriate device based on the patient's unique characteristics.

LymphActivist

[Cassie]

Joe Rapine,
I really appreciate your identifying your business connection to Absolute Medical, as it tends to level the playing field. My first guess in reading your post was that Absolute handles Lymphapress, but not Flexitouch, and a glance through your website did show that to be true. I don't represent either company in any way and certainly don't have anything to gain from promoting either. I read through the "comparison" page you posted and want to clarify that Flexitouch has new, easy-to-don garments, and that there is in fact a great deal of published research regarding the Flexitouch. As LymphActivist so diplomatically points out, the decision about which pump to use has to do with our own individual medical condition, not the advertising of companies that sell only one or the other of them.

Jackie and Nancy, keep asking those questions until you get to the bottom of which are the very best options for YOUR treatment. As for price comparisons, the pump you need is a very specific decision, and the wrong one may be either ineffective or outright damaging. As with every other part of our lymphedema care, the cheapest option may -- or may not -- be the one we need. We'll all do well to be very careful about choosing our treatment options, and do our best to resist the influence of those who have something to gain from promoting their products.
Cassie

[pinkbear]

I do hope you win your battle in getting the insurance to pay for your pump. I did not. I have a lympha press pump and love it. It's not the quick solution I had hoped for but it is making progress and it's easy to use.

The people at LymphaPress USA helped me find one I could afford out of pocket. They were wonderful.

Don't give up the fight!