Insurance Coverage for Lymphedema
Compression Garments and Supplies

What is the Lymphedema Treatment Act and who does it affect?

The Lymphedema Treatment Act (LTA) is a bill that was passed by Congress in December of 2022 to enable Medicare coverage for lymphedema compression garments and supplies. The new coverage went into effect on January 1, 2024. The information below is specific to traditional Medicare, however, most other insurance plans eventually follow Medicare precedent.

What is required for coverage?

• A lymphedema diagnosis. The applicable codes are:
  • Q82.0 Hereditary lymphedema
  • I89.0 Lymphedema, not elsewhere classified
  • I97.2 Postmastectomy lymphedema syndrome
  • I97.89 Other postprocedural complications and disorders of the circulatory system, not
    elsewhere classified
• A prescription for the item or items.
• Clinical notes including stage of lymphedema, and if ordering a custom garment, notes must indicate why a ready to wear garment is not indicated for the patient.

What compression supplies will be covered?

• Custom and standard fit daytime and nighttime garments.
• Custom and standard fit gradient compression wraps with adjustable straps.
• Bandaging supplies for any phase of treatment.
• Accessories including but not limited to donning and doffing aids, padding, linings, and zippers.

What quantities will be covered?

• Daytime garments – 3 sets (one garment for each affected body part) every six months.
• Nighttime garments – 2 sets (one garment for each affected body part) every two years.
• Bandaging supplies – no set limit.
• Accessories – no set limit, determined on a case-by-case basis depending on needs of the patient.

For Patients: What will my out of pocket costs be?
For traditional Medicare, these supplies are covered under Part B, so the annual Part B deductible and 20%
coinsurance apply. For Medicare Advantage and all other types of insurance, out-of-pocket costs will vary
depending on the specific terms of the plan, and will likely be subject to the same copays and deductibles as others supplies covered under the DMEPOS (Durable Medical Equipment, Prosthetic and Orthotic Supplies) section of the policy.

For Providers: What are the codes and reimbursement rates?
There are 78 new codes for lymphedema compression supplies.
Please visit our website for the list of codes and corresponding
reimbursement rates, and for additional information.
LymphedemaAdvocacyGroup.org

Background

An estimated 3-5 million Americans suffer from lymphedema, a buildup of lymphatic fluid that can be painful and debilitating. Compression supplies can be costly without Medicare insurance assistance, and therefore, many patients suffer from worsening progression of their condition without the supplies needed to maintain it. Center for Medicare Services (CMS) does not have the authority to add or redefine benefit categories; only Congress does, which explains the need for legislation.

The first version of the LTA, entitled the Lymphedema Diagnosis and Treatment Cost Saving Act of 2010, was introduced in the 111th Congress. This bill was spearheaded by Heather Ferguson, founder of the all-volunteer Lymphedema Advocacy Group (LAG), whose son was diagnosed with primary lymphedema as a baby. After spending his first years of life appealing denials of coverage for his expensive but needed compression garments, Heather worked with her state representatives and congresspeople to introduce a federal bill. The bill gained momentum in subsequent years and congresses. In 2016, a Senate companion bill was introduced. With each Congress, more and more support has been steadily gained.

What does the Lymphedema Treatment Act do?

The Lymphedema Treatment Act (LTA) will provide Medicare coverage for the diagnosis of Lymphedema by amending the Medicare statute to allow for coverage of compression supplies. Although this legislation relates specifically to a change in Medicare law, it would set a precedent for Medicaid and private insurers to follow. The Lymphedema Treatment Act will amend Sec. 1861 [42 U.S.C. 1395x] of the Social Security Act to enable coverage of these items under Durable Medical Equipment. The main highlights of the passing of this bill will be to:

• Improve insurance coverage for prescribed medical compression supplies
• Reduce total healthcare costs for patients with lymphedema

Timing

The Lymphedema Treatment Act will amend Sec. 1861 [42 U.S.C. 1395x] of the Social Security Act to enable coverage of these items, which will go into effect on January 1, 2024. Medicare will be working with patient advocates and stakeholder groups like LAG through 2023 in order to research and gather information necessary to formulate the details of the bill and coverage properly. This includes researching garment costs submitted by compression garment companies as well as learning the challenges faced by patients who live with lymphedema. Medicare will work with the clinician community to establish guidelines for treatment of coverage.

To learn more information about the Lymphedema Treatment Act and frequently asked questions pertaining to the bill, please visit:

Lymphedema Treatment Act FAQ’s

Lymphedema Advocacy Group