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TRICARE Policy Manual 6010.63-M, April 2021
Other Services
Chapter 8
Section 17.1
Lymphedema
Issue Date:  September 12, 1986
Revision:  
1.0  HCPCS CODES
Level II Codes E0650 - E0673
2.0  DESCRIPTION
Lymphedema refers to edema from accumulation of lymph secondary to obstruction to its flow.
3.0  POLICY
3.1  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 CONSIDERATIONS
A physician’s prescription is required for all claims for the segmental type pumps with or without a calibrated pressure gradient.
5.0  EXCEPTION
Lymphovenous anastomosis by use of a special needle for insertion of lymphatic vessels directly into the veins is not a covered benefit.
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