This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Lymphedema therapy consists of education, skin care, massage, containment wrapping, exercise, gradient compression garments, and lymphedema pumps.

Lymphedema therapy may be considered medically necessary when ALL of the following criteria are met:

• There is a documented diagnosis of lymphedema; and
• The patient is symptomatic (including but not limited to, sense of heaviness, tightness, aching or discomfort in the limb, and restricted range-of-motion, commonly accompanying swelling) with limitation of function; and 
• The patient or patient caregiver has the ability to understand and comply with home care continuation of the treatment regimen; and
• Lymphedema therapy must be delivered by a qualified provider, who has received specialized training in this form of treatment. A qualified provider is one who is licensed, where required, and is performing within the scope of license.

Supporting Documentation Requirements
ALL of the following documentation must be maintained in the medical record and be available upon request.

• A statement as to the ability of the patient/patient caregiver to follow through with the continuation of treatment on a long-term home treatment plan; and
• History and physical which addresses the cause of the lymphedema and any prior treatment;  
  
  
  Components of the history are to include ALL of the following:
  • Age of onset; and
  • Diagnosis of lymphedema; and
  • Area(s) of involvement; and
  • Associated symptoms (including but not limited to a sense of heaviness, tightness, aching or discomfort in the limb, and restricted range-of-motion, commonly accompanying swelling); and
  • Medications–While none is directly associated with an increased risk of lymphedema, some are associated with edematous states (e.g., non-steroidal anti-inflammatory agents) or are contraindicated in the treatment of lymphedema (e.g., diuretics), and
  • Progression of symptoms; and
  • Measurements–A measurement of the body part/extremity must be documented prior to treatment. Clinical measurements of extremity girth are necessary to establish baseline and to track changes during treatment; and
  • Past medical history, including medical conditions associated with lymphedema, any prior travel, infections, surgery or prior radiation therapy (RT); and
  • Family history; and
• Components of the physical exam should evaluate the vascular system, skin, and soft tissue, and palpation of the lymph nodes. If primary lymphedema is suspected, evaluation should include documentation of any physical signs or congenital anomalies associated with an inherited condition; and
• A report showing the progress of the therapy including:
  • Measurements showing a reduction in size of the extremity; and
  • The response of the patient/patient caregiver to the education and their understanding and ability to take on some of the responsibilities of the treatment; and
  • The expected outcome of the treatment as well as the expected duration of treatment.

Manual lymphedema drainage (MLD) therapy is designed to transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient family or patient caregiver. It is expected that the qualified provider's treatment would only last for one to two weeks, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment cannot be achieved unless the patient continues treatment at home.

MLD services are eligible for one hour sessions, three times per week for two weeks.

Repeat Services
When physician treatment of lymphedema using MLD or complete decongestion physiotherapy (CDP) exceeds two weeks, documentation should accompany the request for those services to substantiate the medical necessity of continuation of the treatment. Services that do not meet the medical necessity guidelines are considered not medically necessary.

A patient may require “tune up” lymphedema decongestant massages after minor events (e.g., local infection, trauma, therapeutic injections).  With these subsequent treatments, the same criteria as that of initial treatment must be met.

Maintenance Services
MLD or CDP performed repetitively to prevent regression is considered maintenance and is not eligible for payment.

Evaluation and Management Services
Other services, such as education and skin care, are part of medically necessary evaluation and management services. An evaluation and management service should not be billed unless all of the components of the visit have been met.

Surgical Treatment
The surgical treatment of lymphedema, including but not limited to, microsurgical lymphatico-venous anastomosis and vascularized lymph node transfer techniques is considered experimental/investigational, and therefore, non-covered.  The safety and/or efficacy of this service cannot be established by review of the available published peer reviewed literature.

Lymphedema Pump
Treatment of lymphedema using a lymphedema pump may be considered medically necessary. It is not expected that a patient using a pump would also require manual lymphedema drainage therapy. See Medical Policy Bulletin E-7 for more information regarding Pneumatic Compression Pumps.

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Lymphedema Therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the non-covered service.

• Link to Provider Resource Center for the Medical Policy Update

02/2016, Medical Policy S-69 Cancelled
02/2016, Surgical Treatment of Lymphedema Added to Medical Policy Y-11, Treatments for Lymphedema

• Link to Diagnosis Codes

• Link to References