top of page

Lymphedema Care 

Clinician & Therapist Guide：
Insurance Coverage and Clinical Process for Lymphedema Care

The passage of the Lymphedema Treatment Act (effective January 1, 2024) represents a landmark change in U.S. healthcare, expanding Medicare Part B coverage to include compression garments, bandaging supplies, and related accessories. However, navigating this new system requires a nuanced understanding of both clinical best practice (Complete Decongestive Therapy, CDT) and payer-specific documentation requirements.

 

Therapists play a critical role: they initiate reduction, document progress, communicate with prescribers, and coordinate fittings and supply orders. Even small gaps in documentation can delay access, while effective coordination ensures patients transition smoothly from reduction to maintenance (CMS, 2024; Noridian, 2024; ILF, 2020).

1. Coverage Overview:

Phase 1 – Reduction (CDT)

  • Covered items:

    • Short-stretch bandages

    • Foam padding

    • Cotton liners

    • Cohesive wraps.

  • Therapy sessions: Covered under traditional PT/OT outpatient therapy benefit, subject to therapy caps/medical necessity review.

  • Frequency: Daily CDT is ideal; however, real-world delivery is often 2–3x/week due to insurance and staffing limits. Patient/caregiver training in self-bandaging is essential (ILF, 2020; NCCN, 2025).

​

Phase 2 – Maintenance

  • Daytime compression garments/wraps: Up to 3 per affected body part every 6 months.

  • Nighttime compression garments: Up to 2 per affected body part every 2 years.

  • Accessories: Donning/doffing aids, padding, gloves, foot slips, liners.

  • Pneumatic compression devices (PCDs): Covered under NCD 280.6 only after ≥4 weeks of conservative therapy (bandaging/garments/exercise/elevation) without sufficient improvement (CMS, 2024).

2. Documentation Essentials:

Successful claims hinge on specific, prescriber-signed documentation. Therapists should provide detailed notes to ordering clinicians and suppliers.

 

Mandatory elements in orders:

  1. Diagnosis code (ICD-10: I89.0 – lymphedema, I97.2 – post-mastectomy, Q82.0 – congenital, etc.).

  2. Body part(s) affected (right UE, left LE, bilateral, trunk).

  3. Product type (e.g., “short-stretch bandage set,” “custom flat-knit sleeve and glove,” “nighttime foam-chip garment”).

  4. Compression level (mmHg) – must be specified for garments.

  5. Fit classification – Ready to wear (RTW) vs Made to wear (MTW /custom); justify custom (irregular limb, fibrosis, intolerance to OTS).

  6. Quantity and replacement frequency – aligned with Medicare schedule.

  7. Accessories – listed explicitly (donning aid for arthritis, padding for fragile skin).

  8. Medical necessity statement – must reference function and risk: “Required to prevent cellulitis recurrence, maintain limb volume, and preserve upper extremity function in ADLs.”

  9. Progress measures – document girth or volume change before and after CDT.​

 

Example Documentation Language

  • Reduction supplies:
    “Patient with Stage II secondary lymphedema of LLE (I89.0). Requires multilayer CDT bandaging: short-stretch bandages, Rosidal foam, and cotton liners. Bandaging medically necessary for reduction phase. Prescribed quantities: 4 sets per limb to allow rotation and hygiene.”

  • Maintenance garments:
    “Following stable reduction, patient requires custom flat-knit sleeve and glove, 30–40 mmHg, left UE. Custom indicated due to irregular limb shape and tissue fibrosis. Three garments ordered per 6-month allowance. Nighttime garment prescribed (quilted foam construction, 2/2 years). Donning aid required due to decreased grip strength.”

  • Pump order:
    “Persistent limb swelling despite 4 weeks of supervised CDT, including bandaging, garment use, exercise, and elevation. Girth reduction <5%. PCD E0651 ordered for home management. Physician oversight established.”

3. Clinical Workflow: Step-by-Step:

Step 1: Initial Evaluation

  • Comprehensive assessment: staging (ISL), limb measurements (girth, volume, perometry if available), skin integrity, fibrosis, infection history, functional limitations.

  • Document baseline; bill under PT/OT eval codes.

 

Step 2: Order Reduction Supplies

  • Provide prescriber with a templated order including diagnosis, body part, supply type, frequency, and necessity.

  • Emphasize Medicare now covers bandaging supplies separately (LTA).

 

Step 3: CDT Phase

  • Implement MLD, exercise, multi-layer short-stretch bandaging.

  • Daily if feasible; in real-world outpatient settings often 2–3x/week.

  • Document progress objectively (e.g., “circumference decreased 2.5 cm at mid-calf after 10 treatments”).

 

Step 4: Reduction → Fitting Transition

  • Once limb volume stabilizes, transition to garments.

  • Either therapist fits or patient is referred to a certified fitter (vendor-affiliated or independent).

 

Step 5: Communicate with Ordering Clinician

  • Send updated limb measurements, reduction progress, and recommendations.

  • Provide justification for custom vs standard garments, and list accessories.

 

Step 6: Order Maintenance Products

  • Ordering clinician signs detailed prescription including: diagnosis, garment type, mmHg, replacement frequency, accessories, and justification.

  • Supplier submits claim under correct HCPCS codes (new A-codes for garments, NOC codes for custom).

 

Step 7: Maintenance Phase

  • Educate patient on daily wear, skin checks, infection precautions.

  • Reassess garment fit at follow-up visits. Document tolerance, adherence, and complications.

 

Step 8: Consider Pump Referral

  • If persistent edema despite compliant CDT, document failure of conservative care and request PCD under NCD 280.6.

4. Supplier Landscape (Los Angeles & Online):

In-Person:

  • Active Life Medical (West LA) – garments, fittings, DME supplies.

  • BioHorizons – custom garments, fittings, pump coordination.

  • Apria Healthcare – bandaging, basic garment supply.

  • Hospital-affiliated DME shops (Cedars-Sinai, UCLA).

 

Online (nationwide):

  • LymphedemaProducts.com

  • CompressionGuru.com

  • BrightLife Direct

 

Always confirm DMEPOS accreditation and Medicare enrollment; verify “accepts assignment” to avoid unexpected costs.

Screenshot 2025-08-29 at 9.06.44 AM.png

Scientific References:

  • Centers for Medicare & Medicaid Services. (2024). Lymphedema compression treatment items benefit.

  • Centers for Medicare & Medicaid Services. (2024). NCD 280.6 – Pneumatic compression devices.

  • International Lymphoedema Framework. (2020). Best practice for the management of lymphoedema.

  • Lymphedema Advocacy Group. (2024). Implementation and coverage updates.

  • Medicare.gov. (2025). Your Medicare coverage: Lymphedema items.

  • National Comprehensive Cancer Network. (2025). Survivorship guidelines.

  • Noridian DME MAC. (2024). Lymphedema FAQs and documentation updates.

  • Reich-Schupke, S. (2019). Compression therapy: Indications and evidence.

bottom of page