TRICARE Policy Manual 6010.60-M, April 1, 2015 Other Services Chapter 8 Section 17.1 Lymphedema Issue Date: September 12, 1986 Authority: 32 CFR 199.4(d)(3)(iii) Revision: 1.0 HCPCS PROCEDURE CODESLevel II Codes E0650 - E0673 2.0 DESCRIPTIONLymphedema refers to edema from accumulation of lymph secondary to obstruction to its flow. 3.0 POLICY3.1 Lymphovenous anastomosis by open surgical correction is a covered benefit. 3.2 Lymphedema pumps, both segmental and non-segmental, are authorized durable medical equipment for both institutional and home use. 4.0 POLICY CONSIDERATIONSA physician’s prescription is required for all claims for the segmental type pumps with or without a calibrated pressure gradient. 5.0 EXCEPTIONLymphovenous anastomosis by use of a special needle for insertion of lymphatic vessels directly into the veins is not a covered benefit. - END -