Medicare coverage for garments

Binney4

Just received this notice from Bob Weiss, the insurance advocate for the National Lymphedema Network, advising those on Medicare of how to successfully appeal for payment for compression garments (and bandages). I believe it's still necessary to pay up-front, but the process he describes here is working well for reimbursement. If you need help understanding or following through, contact Bob by email at LymphActivist (at) aol (dot) com. Bob's been tireless in working to get payment for garments--THANKS, BOB!

The following guidance is given to Medicare Suppliers regarding the coverability of medical items as SURGICAL DRESSING Medicare benefits. Authority for the following is Section 100 of Chapter 15 of the Medicare Benefit Coverage Manual which covers Surgical Dressings as authorized by the Social Security Act Section 1861(s)(5). This guidance applies to medical items used in the dressing of debridable wounds. The medical necessity requirements are contained in local coverage determinations (LCDs) and their billing details in accompanying coverage policy articles. 

The coverage requirements described below are, in this layman's opinion, derived from coverage criteria applicable to items used in the treatment of open wounds, and are not applicable to members of other benefit categories like durable medical equipment, prosthetics, orthotics or prosthetic devices, all of which have their individual coverage criteria unique to their medical use or function. It is therefore erroneous to deny coverage to an item before determining in which benefit category it may belong based on its medical function. And yet this is exactly what is done when a lymphedema compression bandage system, a lymphedema compression garment or a lymphedema device is denied because it does not meet the coverage criteria required for a surgical dressing.

I strongly recommend that every Medicare denial of a lymphedema bandage system, compression garment or device be appealed because they can be shown to "replace all or part of ... the function of a permanently inoperative or malfunctioning internal body organ" and "are covered when furnished on a physician’s order." [Section 120, Chapter 15 of the Medicare Benefit Policy Manual, CMS Publication 100-02.] and therefore meet the coverage criteria for a PROSTHETIC DEVICE.

November 09, 2012 Surgical Dressings - Benefit Category Reminder Recently questions have arisen regarding the use of surgical dressings for Medicare beneficiaries. Surgical dressings are afforded limited coverage by Medicare as defined in the Centers for Medicare & Medicaid Services (CMS) Benefit Policy Manual (Internet-only Manual, Publ. 100-2). Chapter 15, Section 100 of the Benefit Policy Manual provides details for coverage of surgical dressings under this benefit: Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other health care professional to the extent permissible under State law. In addition, surgical dressings required after debridement of a wound are also covered, irrespective of the type of debridement, as long as the debridement was reasonable and necessary and was performed by a health care professional acting within the scope of his/her legal authority when performing this function. Surgical dressings are covered for as long as they are medically necessary. Primary dressings are therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin. Secondary dressing materials that serve a therapeutic or protective function and that are needed to secure a primary dressing are also covered. Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings. Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings. Some items, such as transparent film, may be used as a primary or secondary dressing. As a result of this restrictive language, not all wounds are eligible for surgical dressing reimbursement. To be eligible for coverage, at least one of the two following key statutory requirements must be met: The wound must be surgically-created or surgically-modified; or, The wound requires debridement. The DME MAC Surgical Dressings Local Coverage Determination and related Policy Article provides additional examples of situations (not all-inclusive) in which dressings are statutorily excluded from coverage under the Surgical Dressings benefit: Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or, A Stage I pressure ulcer; or, First degree burn; or, Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or, A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle. There must be sufficient information in the beneficiary's medical record regarding the wound(s) (e.g., etiology, size, depth, tunneling/undermining, exudate/escar characteristics, prior treatments) to allow the DME MAC's review staff to determine that the wound(s) meet the applicable statutory coverage criteria. In some instances, it may be clinically appropriate to utilize a particular dressing to treat a wound; however, unless the statutory benefit category requirements for surgical dressings described above are met, Medicare coverage for the surgical dressing is precluded. Claims for surgical dressings that do not meet the statutory benefit requirements will be denied as non-covered (no benefit). Note that if the above statutorily-excluded dressings are billed to Medicare, they must have appended a GY modifier, indicating no Medicare benefit. This statutory exclusion and need for a GY modifier also applies to dressings used for similar situations such as abrasions, cuts, friction tears, ruptured bullae, self-inflicted wounds, "moisture-acquired skin defects" and similar wounds unless they are either (a) caused by or the result of a surgery or (b) documented in the record to have requiredsurgical debridement. Gradient compression stockings merit additional caution. According to CMS, gradient compression stockings that serve a therapeutic or protective function and that are needed to secure a primary dressing may be covered as surgical dressings. The gradient stocking must be proven to deliver compression greater than 30 mm Hg. and less than 50 mm Hg. In addition to these requirements, the basic benefit category requirement of use to treat a surgically-created or surgically-treated wound must still be met. Consequently, Medicare limits the coverage and reimbursement of gradient compression stockings to the following situation: The beneficiary must have an open venous stasis ulcer that has been treated by a physician or other healthcare professional requiring medically necessary debridement. [Emphasis added] Additionally, CMS provides guidance on situations where gradient compression stockings are non-covered: Venous insufficiency without stasis ulcers Prevention of stasis ulcers Prevention of the reoccurrence of stasis ulcers that have healed Treatment of lymphedema in the absence of ulcers When a covered gradient compression stocking is provided to a patient with an open venous stasis ulcer, the modifier AW (item furnished in conjunction with a surgical dressing) must be appended or the claim will be denied as a non-covered service. Finally, note that many of the citations above reference documentation of treatment by the physician or other healthcare professional. Suppliers are reminded that the CMS Program Integrity Manual(Internet-only Manual, Chapter 5) in Section 5.7 states (in part): However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable). Suppliers should refer to the Surgical Dressings LCD and related Policy Article for additional coverage, coding and documentation requirements.

The above are the opinions of a lymphedema patient advocate, advising lymphedema patients of their statutory right to appeal Medicare decisions with which they disagree. The above is not to be interpreted as legal, medical or billing advice, but are the opinions of a non-professional layman. These opinions have been confirmed by over a dozen Administrative Law Judges in over 20 individual cases, where Medicare Contractor denials have been reversed for lymphedema treatment materials.

Robert Weiss, M.S.
Lymphedema Patient Advocate

 

carol57

Binney, Do you know if Bob or anyone else has ever created a sample set of appeal documents that one could use as a model to aid in filing an appeal after Medicare denial of compression coverage?

purple32

 lymphedema compression garment or a lymphedema device is denied because it does not meet the coverage criteria required for a surgical dressing.
 


Thank you, Binney .This something that all of us need to keep our eyes and ears open on when it comes to National Health Care Reform now coming our way. I surely dont care to get into a political battle, (PLS!)  just saying- we need to be our own advocates.

I have already heard of whispers of getting more infrequent mammos etc ... for those who care, be aware !

cinnamonsmiles

I am not sure if I believe this since he states."Consequently, Medicare limits the coverage and reimbursement of gradient compression stockings to the following situation:

• The beneficiary must have an open venous stasis ulcer that has been treated by a physician or other healthcare professional requiring medically necessary debridement. [Emphasis added]"

If we do not have an open ulcer we do not get sleeves?

But then he state,"I strongly recommend that every Medicare denial of a lymphedema bandage system, compression garment or device be appealed because they can be shown to "replace all or part of ... the function of a permanently inoperative or malfunctioning internal body organ" and "are covered when furnished on a physician’s order." [Section 120, Chapter 15 of the Medicare Benefit Policy Manual, CMS Publication 100-02.] and therefore meet the coverage criteria for a PROSTHETIC DEVICE." Which would qualify us for it.correct?

It is a nice idea but I don't see how people are getting around the CMS denial for LE sleeves or it depends on WHO from medicare is reviewing it. Sounds like it is the same as getting approved for disability...it's a crap shoot on who gets it, who doesn't ...

carol57

Cinnamon, Bob has been successful several times, acting as an unpaid advocate and coaching LE patients through the appeal process on this very argument that compression garments are prosthetic devices that compensate for the malfunctioning lymphatic system, and they are not surgical dressings. He is hoping that many will try the argument in appeals, so over time it establishes broad precedent.

Anonymous

Cinnamon -- It's more than a nice idea. He used this argument in my case regarding a request for a night vest and won my second level appeal. He said the night vest was a prosthetic device that compensated for my compromised lymphatic system. I was case #30 in his win column, back in January of this year.




To quote from Bob's notice to Binney, "The coverage requirements described below are, in this layman's opinion, derived from coverage criteria applicable to items used in the treatment of open wounds, and are not applicable to members of other benefit categories like durable medical equipment, prosthetics, orthotics or prosthetic devices, all of which have their individual coverage criteria unique to their medical use or function. It is therefore erroneous to deny coverage to an item before determining in which benefit category it may belong based on its medical function. And yet this is exactly what is done when a lymphedema compression bandage system, a lymphedema compression garment or a lymphedema device is denied because it does not meet the coverage criteria required for a surgical dressing."




I believe the point he is making is that Medicare has various benefit categories - such as wound care, DME, and prosthetic devices - each with their own criteria for coverage. Medicare has been denying LE garments because they don't meet the criteria for wound care, which is a category that covers dressings for open wounds. This is not the purpose of LE garments. Bob's argument is LE garments fall under the category of a prosthetic or prosthethic device and DO meet the criteria for coverage when submitted as such. The issue is that Medicare routinely denies coverage for a submission because it places it under the wrong benefit category of wound care. Bob's approach is to make sure reimbursements are submitted under the correct benefit category related to prosthetics or prosthetic devices.




Bob is not a politician, rather an advocate who tirelessly wades through piles of health coverage regulations, insurance policies, and Medicare coverage, all in the hope of getting better care for lymphedema patients. I am no dummy, but I got the runaround from my insurance co regarding coverage until I was ready to poke my eyes out. Bob handled my appeal, and he examined my policy and pulled together an appeal submission that would make anyone's head spin. His presentation to the appeals committee via phone conference was equally amazing. This man is bright, dedicated, and compassionate and cares about getting coverage for patients.

Binney4

Exactly, Tina. It's complicated, but the way it stands now Medicare will only cover LE garments (or bandages) when there is an open wound, or lymph fluid leakage through the pores. In other words, only for very advanced, neglected LE. Then when the wound heals or the leakage stops, they stop paying again. Completely dreadful! And I actually know women on limited incomes who are waiting for wounds to develop so they could get new garments, which they then must wear for years if the wounds heal.

Bob is advocating arguing instead that the garments are a prosthetic devise for a non-functioning body system (which of course they are), which is a category Medicare covers. So if you are appealing for coverage, this is the path to appeal. And the more of us who appeal and win, the easier it will become to get coverage without having to appeal. In the meantime, since this is all about as clear as mud, Bob is available to help anyone on an individual basis, no charge.

Whew! Thanks, Bob!
Binney