Comment Period Open for Medicare Coverage of Lymphedema-Related Products

• By Laurie Watanabe
• Jul 27, 2023

The Centers for Medicare & Medicaid Services (CMS) has opened its comment period concerning a proposed rule related to the coverage of lymphedema products.

The proposed rule was published in the Federal Register on July 10. The comment period ends at 5 p.m. Eastern time on Tues., Aug. 29.

APTA Praises Upcoming Coverage

Among the professional healthcare organizations lauding the upcoming reimbursement was the American Physical Therapy Association (APTA).

APTA President Roger Herr, PT, MPA, said in a July 14 announcement, “I am thrilled that APTA has been able to advocate on both the legislative and regulatory fronts in development of this landmark new benefit category for lymphedema compression garments. This benefit is a critical first step for patients with lymphedema, but there's more work to be done to ensure that physical therapists are appropriately recognized and compensated for the work they perform during compression therapy.”

The organization noted, “Items covered under the new benefit must use compression, and CMS’s benefit is limited by law to coverage for items only, not services. Still, CMS acknowledges the unique role that therapists play in providing necessary, associated services including measuring, fitting, and training, and has requested stakeholder feedback on several options for paying for associated services.”

Regarding the service involved in lymphedema product selection, the APTA announcement said, “Because fitting and measuring approaches can vary, CMS proposed two paths. In one approach, suppliers of pressure garments would ensure that all fitting, training, and adjustment services are provided and paid for as part of furnishing the item; or in instances in which those services are provided by a non-supplier such as a PT [physical therapist] or occupational therapist, the supplier would provide payment to that provider. Alternatively, when PTs provide these services directly, CMS would consider paying separately for the fitting, and then back-paying for the garment amount.”

While compression products can be used to treat other conditions, the benefit, APTA added, only covers the products if they’re used for lymphedema treatment. The benefit would cover gradient compression garments, as well as ready-to-wear, non-elastic gradient compression wraps and compression bandaging systems “in phase-one decongestive treatment.”

What This Means for DME Suppliers

The VGM Group and its Essentially Women division released additional information on July 18 and noted that the proposed rule “covered multiple topics.”

In the announcement, VGM noted that both standard and custom compression products will be covered: “Language was added that could lead to the inclusion of lymphedema products in future iterations of the Competitive Bid Program.”

VGM added that suppliers seeking Medicare reimbursement for these products must meet accreditation, quality standards, and enrollment criteria.

“Fitting, training, and adjustment services will be included in the reimbursement rate for the product itself — though they did consider having a separate reimbursement rate for the initial fitting and are seeking additional comments around that,” VGM said.

VGM noted that the proposed rule includes proposed reimbursement rates, though “Methodology for custom garments not yet determined.”

And VGM said CMS is proposing limitations of two daytime garment sets replaceable every six months; and one nighttime garment set, replaceable once a year.

VGM recommended sending electronic comments and using file code CMS-1780-P when commenting.