The Lymphedema Treatment Act (LTA) was passed last year, thanks in large part to the tremendous efforts of the Lymphedema Advocacy Group, an all-volunteer organization of lymphedema patients, caregivers, healthcare professionals, and industry partners.
As part of the act, effective January 1, 2024 many lymphedema supplies – including certain garments, wraps, and bandages – will now be covered by Medicare. Below is an overview of the latest coverage rules, as well as some reflection on my experiences during the journey to the passage of this important bill.
NOTE: Some of the coverage rules and prices may still change, which would affect our Durable Medical Equipment (DME) partners as well as patients and lymphedema therapists. This is the latest rules update. Please use the links below to stay up to date, and be sure to follow the Lymphedema Advocacy Group as well. We will keep everyone updated as best as possible as this law is carried out.
From the Lymphedema Advocacy Group: Lymphedema Treatment Act Final Rule Coverage Summary
What 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, fillers, linings, and zippers.
- Daytime garments – 3 sets (one garment for each affected body part) every six months, standard or custom fit, or a combination of both
- Nighttime garments – 2 sets (one garment for each affected body part) every two years, standard or custom fit, or a combination of both
- Bandaging supplies – no set limit in the rule.
- Accessories – no set limit, will be determined on a case-by-case basis depending on the needs of the patient.
- To be eligible for the above coverage, a patient must have been diagnosed with lymphedema and have a prescription for the compression supplies.
- The coverage will begin January 1, 2024. There will be no retroactive coverage, meaning, you cannot submit claims for any garments or supplies purchased or ordered before 1/1/2024.
Codes & Reimbursement Rates
- There will be 81HCSPC codes specifically for lymphedema compression supplies, most of which are new, and the rule also outlines the process for the creation of additional codes in the future if needed.
- The corresponding reimbursement rates for these codes are not included in the rule.
Deductibles & Copays
- For traditional Medicare — these supplies will be covered under Part B, so the annual Part B deductible and 20% coinsurance apply to all compression supplies.
- For Medicare Advantage and all other types of insurance — out-of-pocket costs will vary depending on the specific terms of your plan. It is likely that your compression supplies will be subject to the same copay and deductibles as supplies covered under the DMEPOS (Durable Medical Equipment, Prosthetic and Orthotic Supplies) section of your policy.
The final rule also outlines the process for making future changes to and/or additions to coverage if/when needed. This is very important and ensures we will not be in the position of needing to get another law passed if adjustments to the coverage need to be made, or if new treatment supplies become available and need to be added to coverage.
More Helpful Links
Details of the Bill
These new coverage rules came out of meetings between CMS and numerous stakeholder organizations. They were then modified after input of over 700 comments from therapists, industry representatives and patients alike in response to an initial set of proposed rules released this past summer. The final rules are more generous, and fortunately in an ever-changing world, there is language in place to allow needed changes in the future without requiring an additional act of congress! The final rule was issued on November 1, 2023, and updates are ongoing. Please continue to check back to the linked information for updated information.
The Consolidated Appropriations Act of 2023 included additional changes to Medicare besides the LTA, but the full text of the final rules of the portion regarding Medicare coverage of compression for lymphedema is linked here.
An important consideration to note is that this coverage is specific to patients with a LYMPHEDEMA diagnosis. Although there are many co-morbidities and contributing factors to Lymphedema, and there are other diagnoses that often lead to Lymphedema, without that specific diagnosis, compression is not covered under this ruling. That is important for those who know they benefit from compression, such as patients with Lipedema or chronic venous insufficiency lacking an additional diagnosis of Lymphedema despite that we know that these individuals do benefit from and require compression to achieve a high quality of life.
Also, it is important to keep in mind that, although the coverage officially went into effect on 1/1/24, there will be a medical policy that is still being crafted and will not be in place by that date. Therefore, coverage will be determined on a claim-by-claim basis until such policy is finalized and implemented. So, the initial experience may still be tricky for some of us Medicare patients. This upcoming medical policy will indicate what treatments may have to be tried before coverage is approved such as elevation or manual therapy and will detail how coverage will be determined and whether a patient is appropriate for a standard size or a custom garment.
Bandages and other supplies such as accessories for donning and doffing or padding to use under garments are also covered with various specifications. This is great as many of us use compression bandages for daily care both during the reduction and the maintenance phases and these will be covered when appropriate in both cases. Yay! For those who are doing the compression fittings, there are additional details still to be worked out regarding payment. This article is not going to take on those details at this time, but we may revisit the topic in the future.
There are specific quantities of and frequency for the provision of garments and supplies. Those are detailed in the summary from the Lymphedema Advocacy Group, and they are even more generous than some private insurance has been offering in past years, which is quite hopeful.
New codes have been determined for billing for Medicare and they will not use some of the codes that will continue to be valid for private insurance. But flat versus circular knit products are not specified, and accessories are under just one code so there is the possibility for confusion in the future. The organization of the Lymphedema Manufacturers is still looking into making some changes here.
Pathway to Passage
In 2014, I attended the National Lymphedema Network conference in Washington D.C. As with all of the lymphatic conferences I’ve attended, I was stunned by the amount of new information presented, the passion demonstrated by researchers and providers alike, and by the presence of patient advocates who shared moving and motivating information about their own experiences. Immediately following the end of the conference, a Lobby Days event on Capitol Hill was held by the Lymphedema Advocacy Group (LAG) to promote the Lymphedema Treatment Act (LTA). I was able to get time off from my job at the Lymphedema clinic at Vanderbilt to participate in these events.
I was pretty nervous about the prospect of roaming the halls of congress and speaking to legislators and educating them and their aides about the bill and about Lymphedema in general. I’m basically a bit shy, and I was shaky about the whole prospect of going around with people I hadn’t known beforehand and making a case for an act of Congress to change United States healthcare law. It felt daunting.
It turned out I had nothing to fear; the LAG was truly well organized, and the experience was surprisingly exhilarating! The Lobby Days event got me hooked on this worthy effort and I ended up on the Board of Directors of the organization for several years to follow.
So, after 13 years of lobbying, when the bill passed at the end of 2022 I was thrilled, but the work was not done. This last year has seen numerous meetings and required the input of many individuals and organizations in the process of crafting of rules around the implementation of the LTA.
The LAG continues to be a leader in this endeavor and has provided excellent information regarding the current rules as well as a structure to support continued efforts toward improving access to compression in the private insurance realm.
Celebration of Success
This past May, there was a celebration in Washington D.C. to honor the work of the legislative champions and the activists who brought this dream to fruition. Our AIROS Medical Team was there to participate. CEO Gerald Makoid, VP Darren Behuniak and I joined the large group who gathered in the Capitol Building for the moving moments of recognition for the work of the Senators, Congresspeople and Aides, and particularly for the work of Heather Ferguson, whose personal experience and dedication created this bill. Her grace, intelligence and unceasing work are examples to anyone who endeavors to make a change against all odds.
The Lymphedema Treatment Act passage is a victory for all those who are covered by Medicare, and eventually should also support better coverage by private insurance. We have much to celebrate, but we will have to be alert for hiccups as the final details such as the Medical Policy and the fee schedules are finalized.
Please contact me with any questions or comments you may have regarding the Lymphedema Treatment Act or this article at email@example.com.