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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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