Medicare insurance coverage for patients in need of medical compression to help manage lymphedema outlined in the Lymphedema Treatment Act (LTA) went into effect Jan. 1, 2024. Juzo has been working with Reimbursement Consultant Carmen Anderson to help patients, medical professionals and authorized Juzo dealers better understand the legislation. We asked her to outline the steps patients recently diagnosed with lymphedema should take to receive Medicare coverage, as well as those actively managing with the condition with their care team.
New Lymphedema Patients
In order for insurance to consider coverage and payment of an item, new patients must have adequate documentation in their medical record to support reasonable medical necessity. Different insurance providers may have unique policies and/or documentation requirements. Please review specifics applicable to your individual coverage and eligibility.
Pathway Steps
- Schedule a visit with a clinician—this can be your general practice provider, a physical or occupational therapist or a relevant specialist. Prepare to advocate for yourself.
- Discuss a treatment plan.
- Is decongestive therapy appropriate and accessible?
- Will you need a garment to manage and/or maintain your lymphedema symptoms?
- Request medical record documentation of the following:
- Clinical history and symptoms
- Lymphedema ICD-10 diagnosis code
- Justification for compression (including if a custom product is necessary)
- Determine which of the following compression treatment items may be necessary for you:
- Off the shelf or custom
- Daytime
- Nighttime
- Accessories
- Bandaging Supplies
- Request a prescription.
- Make sure the clinician follows the Medicare Standard Written Order Requirements.
- Identify a DME Supplier.
- Determine if they are contracted with your health insurance provider.
- Get measured and fitted for compression garments.
- Make payment if needed (i.e., copay, coinsurance, deductible).
Maintenance Lymphedema Patients
Per the LTA, Medicare beneficiaries diagnosed with Lymphedema are eligible for the following:
- 3 daytime compression garments every 6 months
- 2 nighttime compression garments every 2 years
- Accessories and bandaging supplies based on clinical need
Medicare beneficiaries may also be eligible for replacements when:
- A garment is lost, stolen, or irreparably damaged.
- They need a new garment or wrap due to a change in medical or physical condition.
For insurance coverage consideration, there should be documentation in the beneficiary’s medical record to support the item continues to remain reasonable and necessary. Different insurance providers may have unique policies and/or documentation requirements. Please review specifics applicable to your individual coverage and eligibility.
Pathway Steps
- Schedule your annual visit with your clinician.
- Discuss your treatment plan.
- Do you need to make any modifications based on increased swelling or other new symptoms?
- Should you consider other compression products that may help better manage your lymphedema?
- Request documentation of the following:
- Relevant clinical history and symptoms
- Lymphedema ICD-10 code
- Continued need for compression
- Select your compression products.
- Request a prescription.
- Make sure the clinician follows the Medicare Standard Written Order Requirements.
- If you’ll use the same products, you will not need a new prescription.
o You will need a new prescription if you change products.
- Identify a DME Supplier.
- Determine if they are contracted with your health insurance provider.
- Get measured and fitted for compression garments.
- Make payment if needed (i.e., copay, coinsurance, deductible).
Disclaimer: This information is solely for general education purposes—not as professional advice. Always seek advice of a qualified attorney or a healthcare professional if you need a medical diagnosis or treatment, as it relates to topics discussed. Do not disregard advice you have received, nor delay getting such advice, because of something you learn from this article.
Talk with your authorized Juzo dealer and care team to get properly fitted for medical compression garments and find out what may work best for you. They also can help you understand the new insurance coverage available. Juzo is a member of the U.S. Medical Compression Alliance. The USMCA website has several helpful resources explaining Medicare coverage.
Follow Juzo on Instagram, @JuzoCompression and Facebook to learn more about our medical compression products, programs and ways we support the lymphedema community.