Lymphovenous Canada: Establishing limits

INSURANCE COVERAGE FOR
TREATMENTS AND MEDICAL EQUIPMENT

Over the years consumers with lymphedema and health care professionals have struggled to convince private insurance and public health care providers of the legitimacy of such treatments as manual lymph drainage (MLD), complex physical therapy (CPT) and complete decongestive therapy (CDT). One of the challenges has been to determine acceptable protocols that private insurance and public health care providers would be willing to fund.

In 1993 the Sir Michael Sobel House in England reported its attempt to establish treatment time frames and protocols for patients with cancer-related lymphedema (Volume reduction of arm lymphedema, Surgical Oncology, Nursing Standard, May 19, Volume 7, Number 35. 29-32).

Authors Karen Rose and Helen Taylor noted, "It was noticed in the lymphoedema clinic that most of the volume reduction during an 11-day course of compression bandaging tended to occur in the first few days. Evidence confirming and quantifying this observation might enable shortening of the bandaging course with implications for workload, cost and patient convenience. Similar observations have been made in reports on short courses of intensive treatment (including bandaging and/or the use of intermittent compression pumps) for lymphoedema."

The study compared the volume reduction in days 1-4 with days 5-11 of an 11 day course of compression bandaging. The study noted that specialist clinics in France and Germany used a prolonged course of 4-8 weeks involving MLD, compression bandaging and exercise, followed by the fitting of a compression sleeve and shorter courses of the former treatments. Most of these treatments were carried out on an in-patient basis.

The authors noted, however, that a 1960's study carried out by G.K. Stillwell at the Mayo Clinic "observed that a reduction of about 30 per cent of the swelling in post-mastectomy lymphoedema occurred in three to four days of treatment with a combination of elevation, mechanical compression pump, massage and bandaging." (Stillwell G.K., Treatment of post mastectomy lymphoedema. Modern Treatment. 1969. 6, 396-412).

"This represented the proportion of swelling which was easily movable, and subsequent progress was slow, whether following this regimen or a much simplified treatment at home. This is comparable with our figure of 36 per cent reduction in swelling after four days of bandaging."

In 1997 Florida agreed to reimburse patients for the costs of complete decongestive therapy (CDT) under medicare for 10 treatments - provided the following protocol was met:

1. There is a physician documented diagnosis of lymphedema: and the physician specifically orders CDP.
2. The patient is symptomatic for lymphedema, with limitation of function related to self-care, mobility and/or safety.
3. The patient or patient caregiver has the ability to understand or comply with home care continuation of treatment regimen.
4. The services are being performed by a health care professional who has received specialized training in this form of treatment.

Health care professionals must also meet the following ICD-9 diagnosis and CPT codes:

• 457.0 - Post-mastectomy Lymphedema Syndrome
• 457.1 - Other lymphedema
• 757.0 - Hereditary edema of the legs (congenital lymphedema)
• 97001 - Physical therapy evaluation
• 97002 - Physical therapy re-evaluation
• 97003 - Occupational therapy evaluation
• 97004 - Occupational therapy re-evaluation
• 97110 - Therapeutic procedure, one or more areas, each 15 minutes: therapeutic exercises to develop strength and endurance, range of motion and flexibility
• 97140 - Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
• 97535 - Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment)direct one on one contact by provider, each 15 minutes

Dr. John MacDonald, who was instrumental in selling the proposal to Medicare Florida, based his proposal on his experiences treating patients with lymphedema in Haiti. In June 2000 at the Symposium for Advanced Wound Care in Dallas, Texas, he reported his findings based on treatments of 232 patients. His treatment team reported that volume reduction and edema reduction in patients who received 10 treatments (which included self-care education), were the same as those reported in Australia and comparable to German and American 4-week treatments.

MacDonald acknowledges that although the treatment is not the "gold standard" treatment available in Europe (which involves two treatment sessions per day), it has permitted thousand of patients to access therapy for lymphedema in his state. Many insurance companies in the U.S. currently balk at funding treatment costs based on the European model which range on average from $10,000 - $15,000 and these costs are out of reach for most ordinary consumers.

For more information on the Florida Protocol and Dr. MacDonald's journey to establish this reimbursement program, see: "Florida Protocol" Medicare and Lymphedema—How it Came to Be. You can contact Dr. MacDonald, who works at the University of Miami School of Medicine, by e-mail at: trappermac@aol.com.