Medicare has issued a Local Coverage Decision (LCD) that will severely restrict reimbursement for pneumatic compression devices (PCDs) for lymphedema patients, according to PCDpolicy.org, a campaign calling urging providers to help reverse the policy.
The new policy change would alter Medicare’s 20-plus years’ coverage of pneumatic compression devices for lymphedema at-home therapy (also called lymphedema pumps). If the policy change is implemented, lymphedema patients will be denied reimbursement for PCDs until the condition is severe and irreversible adverse effects have occurred, according to the online campaign, which is sponsored by compression provider Tactile Medical.
Scheduled to take effect on Dec. 1, the policy was developed and released by four local Medicare Administrative Contractors without a public comment period.
“[The policy] is significantly more restrictive than Medicare’s prevailing national coverage policy for PCDs,” a statement from PCDpolicy.org read “These restrictions and the lack of public input to the policy are in potential violation of Medicare regulations governing coverage policy development and in conflict with the agency’s longstanding position that such devices are a viable treatment option.”
The potential patient population that could be impacted is not small. A life-long condition, lymphedema affects more than five million people in the United States, with more than one million patients eligible for Medicare benefits. Lymphedema is a common result of cancer treatment such as surgery or radiation, but can also be a consequence of other surgical interventions, infections, venous disorders and trauma. Controlling the swelling of limbs and other body parts requires consistent and ongoing treatment.
PCDpolicy.org provided this chart of how various patients could be impacted by the policy change:
Patient Group
Existing Reimbursement Policy
Proposed New LCD Reimbursement Policy
Patients with irreversible lymphedema
For more than 20 years, Medicare has covered reimbursement for PCDs, enabling patients to use a PCD at home to stabilize and improve symptoms before they become severe.
Based on this policy, PCD use will be unavailable, except for those who have progressed to the most severe, debilitating and often permanent symptoms. Patients are likely to suffer permanent disfiguring skin damage, functional impairment, limb deformity, pain and serious infections.
Breast cancer patients
PCDs are now reimbursed to help improve symptoms, restore function, and prevent disease progression for breast cancer survivors with lymphedema.
PCD use will be unavailable, as the new policy’s criteria will virtually eliminate access for most patients with breast cancer-related lymphedema.
Patients with limb-only lymphedema
Advanced PCDs have, for two decades, been used (and reimbursed) for patients with limb-only lymphedema.
Advanced PCDs will no longer be covered for these patients, even when all other therapeutic options have failed.
Patients who experience improvement during more conservative therapies
Patients can be reimbursed for PCDs if a physician determines that “significant symptoms still remain” after use of conservative therapies.
Patients will not receive reimbursement for PCDs regardless of physician determination that significant symptoms or disability remain after use of conservative therapies.
Privately insured patients
PCDs are frequently covered by commercial insurance.
Patient access to PCDs would likely worsen if commercial health plans follow the CMS policy. This outcome is likely unless patients and physicians act now.
Source: PCDpolicy.org
PCDpolicy is urging providers to contact their legislator before Dec. 1 urging them to request CMS withdraw the pending policy. Share opinions on the proposed policy and the impact it will have online at PCDpolicy.org and on social media via #PCDpolicy.