Skip to main content

Military Health System

Utility Navigation Links

Need larger text?
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 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.
- END -
You are leaving Health.mil The appearance of hyperlinks does not constitute endorsement by the Defense Health Agency of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website. You are leaving Health.mil View the external links disclaimer.
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery