Other Services
Chapter 8
Section 17.1
Lymphedema
Issue Date: September
12, 1986
Revision:
1.0 HCPCS PROCEDURE
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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