It is now required for prescribed lymphedema compression garments to be covered by Medicare, according to the recent Lymphedema Treatment Act.
Medicare will now cover doctor-prescribed compression supplies for patients with cancer and other conditions who are experiencing lymphedema, thanks to the Lymphedema Treatment Act.
The act, which was signed into federal law on Dec. 23, 2022, went into effect on Jan. 1, 2024. According to its summary on congress.gov, “Specifically, the bill provides for coverage of standard and custom-fitted gradient compression garments and other approved items that are prescribed by a physician or other specified health care professional to treat lymphedema.”
Lymphedema is a swelling of the arms or legs and commonly occurs in patients with breast cancer who have surgery to remove the lymph nodes. While there is no cure, certain compression garments, massage and exercises have all been shown to help.
READ MORE: Improved Way to Predict Breast Cancer-Related Lymphedema
Coverage of compression garments for lymphedema could help alleviate some of the financial stress that patients with cancer encounter, explained Joanna Fawzu Doran, CEO of Triage Cancer, a nonprofit organization that provides education on legal and other issues that patients with cancer face.
“Frankly, this has been a very long road. There have been a number of organizations in the advocacy community who’ve worked very hard to get this coverage passed for decades even to try to get coverage for these types of garments, which are not inexpensive,” Doran said in an interview with CURE®. “So, patients having to pay out of pocket for these types of garments have been a challenge for patients in the past.”
Patient and Provider Knowledge Is Key for Coverage
Doran explained that this is the first time that the Center for Medicare & Medicaid Services (CMS) has offered clear coverage, under Medicare Part B, for lymphedema compression garments.
Now that the act is law, it is essential that patients — and their providers — know about the rights and coverage surrounding lymphedema products.
“If patients are getting access to these types of garments, they need to be making sure that they’re going to a provider that can bill Medicare. And if they aren’t going to a provider that can build Medicare to get access to these garments, they can be submitting those claims to Medicare themselves,” Doran said.
Doran noted that when Medicare sends a letter denying coverage of something, instructions for filing an appeal may be found in small print or on the backside of the letter.
“We (at Triage Cancer) also have a tool that helps people navigate the appeals process based on the type of insurance that they have,” she said, also mentioning that the CMS website has a useful tool for patients and providers to understand exactly which products are covered.
Medicare Can Pave the Way for Private Insurers
The Lymphedema Treatment Act is a major step forward but still does not make it law that private insurers must cover compression sleeves for patients with lymphedema. However, Doran is hoping that Medicare’s coverage will pave the way for other insurers to do the same.
“This is a good first step in the process, but it does leave out a large number of patients where we hope to see coverage in the future,” Doran said. “While it is very limited in its scope, we hope that it actually has a lot of impact on patient access for a number of reasons. One, this is the first time where we’ve seen coverage for lymphedema compression garments at the CMS level. And private insurance often follows what Medicare does in terms of coverage. So, we hope to see that this is the first step in an expansion of access to this type of care.
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