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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say Lymphedema, as discussed below, is just one group of conditions that can be a cause of accumulation of fluid in the tissue. Lymphedema arises from disorders of the lymphatic system. It is essential to rule out other causes of edema in order to diagnose lymphedema. Edema from other causes is not classified as lymphedema for purposes of Medicare reimbursement for PCDs (E0650, E0651, E0652). A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 1. The beneficiary has a diagnosis of lymphedema as defined above, and 2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings: Marked hyperkeratosis with hyperplasia and hyperpigmentation, Papillomatosis cutis lymphostatica, Deformity of elephantiasis, Skin breakdown with persisting lymphorrhea, Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and 3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A PCD coded as E0650 or E0651 is covered for the treatment of CVI of the lower extremities only if the patient has all of the following:
Edema in the affected lower extremity One or more venous stasis ulcer(s) The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating practitioner. (See below for trial guidelines.) A PCD coded as E0650 or E0651 used to treat CVI that does not meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A PCD coded as E0650 or E0651 used to treat ulcers in locations other than the lower extremity or ulcers and wounds from other causes is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651 is required. The four-week trial of conservative therapy must include all of the following: At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided Compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid movement and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal to proximal. The compression used must not create a tourniquet effect at any point. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression starting with a minimum of 30 mmHg distally. Regular exercise Elevation where appropriate Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 minutes per day Evaluation of diet and implementation of any necessary change Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) Correction (where possible) of anemia and/or hypoprotenemia PCD related accessories (E0667) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related accessories are not eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.