Medicare Cuts Coverage for Lymphedema Patients

Men and women battling cancer are shedding their patient statuses with each successful surgery and effective radiation treatment, however, as one battle ends, another begins. The latest hurdle for them is a change in Medicare B coverage for use of pneumatic compression devices (PCDs) to treat secondary lymphedema that will take effect December 1.

Secondary lymphedema is caused by damage or blockage to the lymph system as a result of infection, injury, cancer, removal of lymph nodes, radiation to the affected area, or scar tissue from radiation therapy or surgery, according to the National Institute of Health (NIH). Although a chronic condition, secondary lymphedema can be managed in a number of ways and lymphedema therapists, researchers and patients want the public to know that many of these therapies actually work together to improve patients’ limb function.

“A lot of people think that therapists will use the pump to replace the manual therapy, but the manual therapy and the pump work in two totally different ways,” said Cynthia Shechter, owner and director of ShechterCare in New York. “We have compression devices in the office and typically we start the session using a basic pneumatic pump and the reason we do that is it’s sort of a nice preparatory way to get the limb ready for manual therapy.

Medicare currently reimburses PCDs for those diagnosed with secondary lymphedema as they’ve done for the last 20 years. During that time they’ve enabled older patients to manage their condition at home. This is especially important to the nearly 1 million lymphedema patients eligible for Medicare. Mobility could already be a cause of concern for this 65 and over population who may have to rely on a family member to bring them to therapy appointments.

“My biggest fear as I get older is will I become less flexible?” said Andrea Weinreb, 59 who was diagnosed with secondary lymphedema in 1998. “It’s really hard to do stuff when you have lymphedema, it’s really hard to put on your compression stockings; it’s hard to do anything.”

Weinreb, a survivor of cervical cancer, began using a Bio Compression System Sequential Circulator after undergoing lymph nodes transfer surgery in 2008. She wouldn’t have been able to afford the device on her own so she says she’s lucky she had 100% coverage for the device under her insurance plan. She’s wary though of Medicare’s new local coverage decision (LCD) which requires a patient to have a severe stage of lymphedema or have had conservative treatments fail in order for a pneumatic compression device to be deemed “reasonable and necessary.” “If I learn that Medicare is worse than what I’m used to then I’m going to have a problem when I turn 65 because I’m going to need what I need.”

Lymphedema societies like the Lymphatic Education & Research Network and the National Lymphedema Network are urging the Centers for Medicare & Medicaid Services (CMS) to withdrawal the LCD policy for both medical and technical reasons because of patients like Weinreb.

“They’re effectively removing access to treatments for patients that have few treatment options,” said Maggie Thompson, vice president of payer relations and government affairs for Tactile Medical. Not only that, she explained the contractors who decide LCDs have also committed a procedural violation of Medicare’s National Coverage Determination (NCD).

These determinations work similarly to the way state and federal laws work. Just as state laws cannot restrict a citizen’s rights afforded them under federal law, a local coverage decision cannot contradict what is covered under a national coverage decision.

Medicare is following suit of other private insurance companies that have made similar requirements for patients to be reimbursed for PCDs. The fear is more companies could follow suit if Medicare’s LCD goes through.

Plus, they made the LCD announcement on Oct. 15 without providing the minimum 45-day public comment period.

“It’s very confusing to many of us as to how they arrived at these conclusions around this algorithm for not paying for pneumatic compression pumps until the patient is more severe,” said Nicole Stout, DPT, CLT-LANA who is a member.

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One theory behind their decision is cost. In 2014 Medicare paid approximately $24 million for pneumatic compression devices out of a $597 million budget according to their Part B National Summary. That same year Stanford University researchers studied patients with cancer-associated lymphedema using PCDs and found that the average annual cost of care for a patient with the condition decreased from $62,190 to $50,000 a year when the patient used the device to treat their swelling (https://med.stanford.edu/news/all-news/2014/12/lymphedema-home-treatment-improves-outcomes–reduces-costs–rese.html).

“There is no evidence to say to us that says we shouldn’t use the device until the patient gets to be more severe,” said Stout. “It’s very constraining to the patients and maybe even putting some at harm who could utilize the device to help them keep their condition in a less-severe stage.”

If the LCD goes into effect, Medicare patients do have the right to appeal the coverage decision but Thompson said this is a long multi-step process. The U.S. Dept. of Health and Human Services estimates an average processing time of 547 days.

“I have patients all the time who get denied for a device,” said Shechter. Often Shechter is able to get the denial reversed by writing an appeal letter attached with articles and evidence on behalf of her patients.

The bottom line though is precious time to treat lymphedema and keep it in check. Now through Nov. 30, Tactile Medical is asking the public to contact their legislators and urge Medicare to withdraw the policy (http://pcdpolicy.org/).

Chelsea Lacey-Mabe is on staff at ADVANCE. Contact clacey-mabe@advanceweb.com.

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