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
4.1 A physician’s prescription
is required for all claims for the segmental type pumps with or
without a calibrated pressure gradient.
4.2 When purchased or rented
as durable medical equipment, prior authorization is required for
coverage of pneumatic compression devices, including intermittent
pneumatic compression pumps and sequential pneumatic compression
devices, to demonstrate that the requested pump is medically necessary
and appropriate for the patient’s specific medical needs, as determined
by the ordering physician based on the individual patient’s specific condition
and severity, risk factors, and keeping in practice with published
national clinical practice guidelines and recommendations from the
American Venous Forum (AVF), American Vein and Lymphatic Society
(AVLS), and the Society for Vascular Medicine (SVM). This determination
shall be confirmed by the contractor as part of their prior authorization
review prior to coverage, including documentation of the specific
patient indications for intermittent pneumatic compression or sequential
pneumatic compression. Generic prescriptions or requests for authorization without
evidence of this evaluation should be returned for additional documentation,
to include length of anticipated need. Initial authorization shall
not exceed 180 days, and continued coverage may be approved upon adequate
documentation from the prescribing physician.
5.0
EXCEPTIOnExclusions5.1 Lymphovenous anastomosis by
use of a special needle for insertion of lymphatic vessels directly
into the veins is not a covered benefit.
5.2 Non-pneumatic compression
devices (e.g., Koya Dayspring) are unproven for the treatment of lymphedema.
