Lymphedema and Insurance

Insurance coverage is a tricky topic when it comes to lymphedema. In order to understand it, you will need to understand the way our insurance system works. There are typically 3 different types of insurance payers in the United States: Medicare, Medicaid, and Private Insurance. Within each of these payers there are many plan options, each with different, patient-specific benefits. Because of this decentralized system,  it is difficult to make broad statements about how lymphedema fits into insurance coverage and reimbursement in the U.S., and coverage even varies state by state.

Here are some things you should know that might help you along your way.

  1. Lymphedema treatment and garments are often categorized differently. While many insurance companies will cover you to see a Certified Lymphedema Therapist (CLT), not all of them will cover lymphedema garments. Take Medicare for example. Medicare will typically cover a certain number of sessions with a CLT. However, Medicare currently does not cover lymphedema garments except for patients with open wounds. Your CLT likely has experience with these matters or can help you get in touch with a biller at a Durable Medical Equipment shop. 
  2. Some private insurance companies will pay for garments out of your Durable Medical Equipment (DME) allowance that is detailed in your insurance plans. If you don’t have your paperwork handy, you can call your insurance company and ask for details about your DME allowance. Some people find that knowing their benefits before mentioning the word lymphedema can be helpful. The better informed you are, the more you can advocate for the care you need. 
  3. Remember that the squeaky wheel gets oiled. You are your own best advocate for your care. If your insurance company denies your claim, be persistent. Often the person you first speak to at an insurance company does not know much – or anything – about lymphedema, and is not the correct person to speak with. There are different levels of employees at all insurance companies including supervisors and medical directors. If you’re not getting the answers you want, you might need to speak to someone else in the company. Do not be afraid to ask for a supervisor.
  4. Letter of medical necessity: Sometimes all your insurance company needs is a letter of medical necessity from your medical professional explaining lymphedema, its treatment, and devices, in order to have coverage. Find out who needs to supply this letter for you (it might need to be your referring doctor and not your CLT) and ask for help. 

Support the Lymphedema Treatment Act, which has bills pending to try to require insurance coverage of lymphedema garments. Learn more at www.lymphedematreatmentact.org.