Lymphedema Devices
DESCRIPTION
Lymphedema is an abnormal accumulation of lymphatic fluid in subcutaneous tissue. This might be the result of a congenital anomaly or damage to the lymphatic system (e.g., removal of lymph nodes, blockage of lymphatic channels by a tumor, scarring of lymphatic channels from radiation, or as a result of surgery or trauma). Lymphedema might occur immediately following surgery or years later. Lymphedema is a chronic condition for which there is no cure. If the condition is not treated it can result in skin deterioration, fibrosis, and loss of limb mobility.
Pneumatic compression devices use compressed air to apply pressure to the affected limb. This forces excess lymph fluid out of the limb and into central body compartments, where lymphatic drainage should be preserved. There are several types of compression pumps. There are single compartment devices, and multi-chamber devices with fixed pressure in each cell. In addition, there are multi-chamber devices with manually calibrated pressure in each cell. These systems consist of a pneumatic sleeve or boot that is attached to a compression pump via hoses. The appliance is intermittently inflated with air, which provides a squeezing or "milking action" to facilitate the flow of lymph from the affected limb. The appliance then deflates allowing for circulation within the limb. Repeated cycles reduce the lymphedema. Following treatment, a pressure garment is worn on the extremity.
POLICY
Lymphedema compression pumps, segmental and non-segmental, for the treatment of intractable lymphedema involving one or more limbs, are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
See also: Manual Lymphedema Drainage (MLD)
MEDICAL APPROPRIATENESS
Lymphedema compression pumps, segmental and non-segmental, for the treatment of intractable lymphedema involving one or more limbs, is considered medically appropriate if ALL of the following criteria are met:
Device is prescribed and progress is monitored by a physician
The individual has failed to respond to ALL the following conservative measures:
Limb elevation
Exercise
Manual lymphedema drainage
Compression garments
ABSENCE of ALL of the following:
Infection
Venous or arterial occlusive disease
Venous thrombosis
Massive edema secondary to congestive heart failure
Metastatic disease in the involved extremity
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2003, April). Lymphedema pumps (1.01.18). Retrieved June 2, 2006 from BlueWeb. (0 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, April). Pneumatic compression (NCD 280.6, p. 2-128). The Ingenix Complete Guide to Medicare Coverage Issues.
Mayrovitz, H. N. (2007). Interface pressures produced by two different types of lymphedema therapy devices. Physical Therapy, 87, (10), 1379-1388. (Level 4 Evidence - Industry sponsored)
National Cancer Institute. (2008, September). Lymphedema. Retrieved June 2, 2009 from http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/healthprofessional/allpages.
Szuba, A., Achalu, R., & Rockson, S. G. (2002). Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer, 95 (11). 2260-2267. (Level 3 Evidence - Independent study)
U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. (2005, May). NCD for durable medical equipment reference list (280.1). Retrieved June 2, 2009 from http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.1&ncd_version=2&basket=ncd%3A280%2E1%3A2%3ADurable+Medical+Equipment.
U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. LMRPs/LCDs for CIGNA Government Services. (2008, November). LCD for pneumatic compression devices (L5017). Retrieved June 2, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=5017&lcd_version=30&basket=lcd%3A5017%3A30%3APneumatic+Compression+Devices%3ADME+MAC%3ACIGNA+Government+Services+%2818003%29%3A.
U. S. Food and Drug Administration. (2006, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K062818. Retrieved June 2, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K062818.pdf.
U. S. Food and Drug Administration. (2008, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082149. Retrieved June 2, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K082149.pdf.
Wilburn, O., Wilburn, P., & Rockson, S. G. (2006). A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412]. BMC Cancer, 6 (84). (Level 4 Evidence - Industry sponsored)
ORIGINAL EFFECTIVE DATE: 6/1998
MOST RECENT REVIEW DATE: 7/9/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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