Lymphedema Pumps
Physician Information Sheet

From DMERC Medicare Advisory, September 1996, Region "C"

These are also known as pneumatic compression devices. They should be used as a Treatment of Last Resort for truly refractory lymphedema, associate with congenital and acquired conditions resulting in lymphatic blockage. Examples of such conditions would be Milroy's Disease. Lymphedema praecox and tarda, malignancies that involve axillary or pelvic lymph nodes, or surgery and/or radiation that have the same effect. Lymphedema pump devices are ONLY COVERED AS A TREATMENT OF LAST RESORT, i.e. other less intensive treatments must have been tried first and found inadequate. Such conservative treatments that should be first tried include:

  • Limb elevation,
  • properly applied compression dressings (as with elastic bandage wrapping), and
  • the use of CUSTOM-FABRICATED gradient-pressure compression dressings. Such producrts are individually fitted items, that require special order and fitting according to each patient's affected limb measurements.

Each of the above measures requires significant compliance by the patient and close management and follow-up by the physician.

National Medicare policy also allows for coverage of Lymphedema pumps in the treatment of chronic venous insufficiency (CVI) which has resulted in venous stasis ulcers on the affected limb(s). These ulcers must have persisted despite a minimum of 6 months of a treatment regimen including each of the above conservative components listed, in addition to the usual drug regimens used to address the underlying conditions which result in CVI. The same degree of patient compliance and close physician oversight is expected during such conservative treatment measures.

Pneumatic compression devices may be covered by Medicare only when prescribed by a physician and when they are used with appropriate physician oversight, i.e. physician evaluation of the patients's condition to determine the medical necessity of the device, suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment.

Types of lymphedema pumps

The DMERC RMRP classifies lymphedema pumps into three basic categories. Those represented by the Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) code E0650, have compressors which have only a single outflow port, producing one pressure, that is then transmitted by connected tubing to a sleeve ("appliance") which wraps around the affected limb, and thereby exerts this single pressure over the entire limb, effecting lymphatic or third space fluid drainage back into the central circulation. There are available some sleeves which attach to this single port, but which supply a preset differential of pressure to distally segmented compartments. Such systems are still considered as single- ported, non-segmented E0650 pumps.

Models of pumps designated by HCPCS code E0651 are truly segmented pumps, wich have multiple ports on the pump delivering either different levels of pressure from each, or the same level of pressure, but at sequentially different times. Each port is connected to a separate segment of limb sleeve by its own tube. Therefore, either by sequentially timed inflation (from most distal to most proximal segment), or by differential pressures (highest most distally to lowest most proximally), a "milking" of fluid toward the central circulation is theoretically effected. E0651 pumps have preset pressures which do not allow for individual calibration of pressure at each port. This, once the most distal pressure is determined, all the other more proximal segments are predetermined by that setting.

Lymphedema Pumps Physician Information Sheet

An E0652 device also had a segmented, multi-ported pump which allows for INDIVIDUAL PRESSURE CALIBRATION at each port. The purpose for such a device would be to decrease the pressure over a discrete area of the limb (such as a painful lesion) and yet still maintain distal-to-proximal decreasing pressure gradient along the entire limb. An E0652 must allow for manual calibration of pressure at individual ports on a minimum of three of the pump's outflow ports. Again, merely fitting an E0650 pump with tubing or sleeves that divide the generated single pressure into some gradient of pressure at the limb does not convert the device into an E0652 The following devices are reimbursed
by Medicare in these approximate amounts
E0650....................................$600.00
E0651...................................$800.00
E0652............$4,000.00-$6,000.00

When a pneumatic compression device is covered, a non-segmented device (E0650) or segmented device without manual control of the pressure in each chamber (E0651) is generally sufficient to meet the clinical needs of the patient. When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation of medical necessity in the individual case. Full payment for HCPCS code E0652 will be made only when there is a painful focal lesion (e.g. significant sensitive skin scar or contracture) of the extremity which requires a reduction in pressure over the affected segment that can only be provided by an E0652 device. There must be documentation that an E0651 device or its equivalent had been tried and had caused significant symptoms that were improved with this use of an E0652 device.

As you are aware, any compression treatment for edema resulting from CVI or lymphedema unaviodably causes some degree of pain. Therefore, careful consideration should be given to the significance of pain being produced by any lesion thought to require an E0652.

Documentation

As with all itmes for which the DMERC must determine whether Medicare may reimburse, our primary contact with the physician ordering these items is the documentation sent in with the claims for the items, or which is supposed to be available in the supplier's filies or the patient's medical record for subsequent review by the DMERC.

  • The physician is expected to complete a DMERC CMN for lymphedema pumps. The CMN is supposed to show the physician the cost of the items being ordered. The physician question section (Section B) of the CMN is not to have been completed by the supplier. It must be completed,or at leat reviewed, signed and dated by the ordering physician.
  • In addition to completing the few questions listed on the CMN, it is necessary to further document the ETIOLOGY OF THE CONDITION LEADING TO LYMPHEDEMA OR CVI with venous stasis ulcers.
  • There should be documentation of the CONSERVATIVE MEASURES used to treat the condition prior to ordering the lymphedema pump.
  • If being ordered for CVI, the number, location, size and history of the venous ulcers must be indicated.
  • If an E0652 pump is being ordered, the following ADDITIONAL PHYSICIAN INFORMATION must be submitted on a signed and dated statement, submitted with the claim:
    1. whether the patient has been treated with custom fabricated gradient pressure stockings/ sleeves, approximately when, and the results;
    2. the treatment plan, including the pressure in each chamber, and the frequency and duration of each treatment episode:
    3. the location, size and etiology of the painful focal lesion which necessitates the use of this pump;
    4. whether a segmented compressor without calibrated gradient pressure (E065 1) or a nonsegmented compressor (E0650) with a segmented sleeve had been tried and the results:
    5. why the features of the system that was provided are needed for this patient; and
    6. the name, model number, and manufacturer of the device.

Completing all of the above information will assist the DMERC Medical Review Unit in properly determining whether a claim for this costly equipment is medically necessary, ACCORDING TO MEDICARE COVERAGE CRITERIA. Since these devices may currently be sold outright (not necessarily rented), your ordering a Iymphedema pump is not an insignificant decision. If you encounter difficulty determining answers to the above questions, you may need to consider if all the mentioned criteria have indeed been fulfilled.

Thank you for your cooperation in our effort to preserve the viability of the Medicare Trust Fund, the same one from which your professional services are also reimbursed.

Paul D. Metzger, M.D.
Medical Director, Region C DMERC
Palmetto Government Benefits Administrators
Columbia, S.C.