Lymphedema stakeholders push for fair reimbursement

WASHINGTON – Lymphedema stakeholders say they are pleased overall with CMS’s proposed plans to cover compression garments, but they say more needs to be done to ensure that it’s not just “coverage on paper.”  

CMS on June 30 issued a proposed rule containing provisions to establish a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items, as required by the Lymphedema Treatment Act, which was included in an omnibus bill passed by Congress in December.  

“We thought there was a lot of good and that they listened to the concerns and priorities we raised,” said Heather Ferguson, founder and executive director of the Lymphedema Advocacy Group. 

The group applauded CMS’s decision to cover a broad spectrum of standard and custom-fitted gradient compression garments, wraps, bandaging systems and supplies. 

It also applauded the agency’s recognition that patients may have lymphedema in more than one area of the body, requiring multiple garments. 

“For me, it’s both legs and the abdomen area, so them recognizing that patients might need more than one area covered shows they did their work in acknowledging the quantities we would need,” said Sarah Bramblette, board chair and lymphedema patient. 

As CMS continues to hammer out the details of the benefit, stakeholders remain concerned with reimbursement rates and payment methodologies, says Ferguson. CMS has proposed that the rates will be based on existing rates from Medicaid and Tricare, which can be low and vary by state. 

“Obviously, we would like to see more standardized reimbursement rates because there’s been a growing problem in the private insurance market with them slashing rates,” she said. “It’s important that rates be fair for (suppliers), manufacturers and patients or that creates another access issue for patients.” 

Stakeholders also believe CMS shouldn’t apply the typical reimbursement model for DME – bundling items and services – to compression garments. It’s not unusual for compression garments to be fitted by a therapist or other professional not employed by the DME supplier, but as it currently stands, only the supplier would be reimbursed and the supplier would be responsible for paying the fitter, says Ferguson. 

“There’s no reason they have to follow the DME payment model,” she says. “For the DME used to providing the garment, nothing would change, but it’s only fair that (the outside fitter) should be reimbursed.” 

All the “good stuff doesn’t matter” if the reimbursement rates aren’t there, says Bramblette. 

“Compression is the cornerstone of treatment,” she said. “I don’t want it just to be coverage on paper.  

CMS is accepting comments on the proposed rule until Aug. 29.