By Robert (Bob) Weiss, MS, LE Legislative Advocate
As regular readers of this column will realize, the efforts to change reimbursements for lymphedema treatment materials is being directed in two distinctly different directions. We are urging patients, therapists and suppliers to appeal every denial of compression bandages and garments to convince insurers (including the Centers for Medicare and Medicaid Services, CMS ) that there truly is a problem with lymphedema treatment policies.
This grass-roots effort is gaining momentum, with eight U.S. Administrative Law Judges ruling in ten cases that compression items used in the treatment of lymphedema meet the statutory definition of “prosthetic devices” and are covered by Medicare. Similar determinations have been made in a small number of private insurance cases. Two more Medicare cases are scheduled to be decided by the time you read this column. Some of these cases are being followed up with requests for Medicare Contractors and Insurers to change current policy in consonance with the ALJ's rulings without waiting for a national coverage determination which CMS refuses to undertake.
These grass roots efforts are attempting to obtain coverage of compression materials by modifying reimbursement policy with new interpretations of current laws. As a backup to these efforts, which are tedious and time consuming and require payment up front and then appealing reimbursement claims, we are pursuing attempts to change the law. Progress on this front have been reported in this column in previous issues. This year has been bad nationally because the intense attention to rising healthcare costs, Medicare viability and Medicare prescription drug programs have all but precluded any efforts to address individual problems such as the failure of Medicare to cover lymphedema treatment. We have had no success in finding a legislator to introduce the “Lymphedema Diagnosis and Treatment Cost Saving Bill”.
Attempts to pass State lymphedema treatment mandates have not resulted in any lymphedema treatment laws since Virginia passed a lymphedema treatment mandate in 2003. The twelve lymphedema-related bills introduced in the New York Legislature are stuck in Committee despite our efforts to report them to the floors of the Assembly and Senate. The only bright spot is the budgeting of $100,000 for a national lymphatic disease patient registry and tissue bank at the Feinstein Institute for Medical Research at the North Shore-Long Island Jewish Health System. We must renew our resolve to prevail on our elected representatives to introduce and pass new lymphedema legislation and fix faulty laws such as therapy caps, lack of practice standards for lymphedema therapists and lack of coverage of lymphedema compression bandage systems and garments
Robert "Bob" Weiss, M.S.
NLN LE Legislative Advocate