Insurance coverage for healthcare can be a confusing and frustrating puzzle to figure out. This is especially true for lymphedema treatment and garments. Coverage for treatment has improved a great deal over the years, but now the difficulty lies in the high copays and deductibles.
Even though most insurances cover lymphedema therapy, they usually limit the number of visits that the patient can have per year, or even in a lifetime. Patients might also have different treatment allowances for occupational therapists and physical therapists for lymphedema treatment, so it is important to think about what their benefits include when planning their treatment. Because of this, garments become even more important to be able to teach the patient how to control their lymphedema and give them the tool to do so.
The only time Medicare will cover a compression garment is when a patient has a wound and is being treated by a physician. Otherwise, garments are not covered. If you have a secondary insurance, they may cover compression garments but you will need to get a Medicare denial first. If the patient has a supplement to their Medicare plan, they typically only cover the items Medicare will cover so compression garments will not be covered. Even though Medicare patients usually pay out of pocket, the CLT should still be involved in the decision making process for garment type and compression. All garments still need to be fit correctly for size by either the CLT or certified fitter.
Most private insurance companies will cover compression garments. Some companies will not cover stockings as they consider them “cosmetic” but will cover compression sleeves. Even if insurance does not cover compression stockings they do typically cover non-stretch garments or bandage alternative garments. Usually the patient will have a deductible to meet and then the garments are covered at a percentage until they meet their out of pocket maximum. At that point, garments are often covered at 100%. It is helpful for the patient to call their insurance company and find out this information. However, be aware that when they call for this information that each insurance company has different medical supply companies that they are contracted with to supply the compression garments. They can ask for a list, but not all or possibly none of the listed companies will carry compression garments or be able to order custom made garments. It is often best to call a medical supply company that deals mainly with lymphedema products. They will be able to tell you if they are in your patient’s network and if not, may be able to tell you which company is in network. Most of these companies will also work with the therapist and physician to get all the paperwork that is needed to obtain garments.
Breast Cancer Patients
We all know that prevention is an important part of our health. Recently there has been a move toward a more preventative approach to treating breast cancer patients. Studies have shown that if a breast cancer patient is evaluated early on in their journey, and then monitored through their treatment and after, there is a chance to prevent or lessen some of the problems such as lymphedema and range of motion issues. Educating patients about these issues and seeking early treatment has also proven to be cost effective for the patient and healthcare system. This preventative approach relies on referral of the patient shortly after diagnosis. This can be tricky if the patient does not present with a problem or complaint as far as a diagnosis for therapy reimbursement. Some clinics have reported luck with using a breast cancer code to cover these visits. They are usually one-time evaluations to get baseline measurements for the patient and to educate the patient about lymphedema prevention and exercises to maintain motion and strength throughout their treatment.