Problem Solvers

Specialized Compression

Understanding unique compression needs and 
treatments for lymphedema patients.

• By Joseph Duffy
• Sep 01, 2010

The population of lymphedema patients in the United States ranges from between 6.8 million and 10 million sufferers, depending on which estimates are used, but one fact is resoundingly clear: there is a large patient segment that needs help from providers of compression therapy and supplies, and treating them requires specialized skills and product knowledge.

Lymphedema sets in as a result of the lymphatic system breaking down. As a result, fluid accumulates in the interstitial tissue causing swelling which often occurs in the limbs. Besides disfigurement from the swelling, the condition carries an increased risk of infection.

Treatment focuses on trying to improve the flow of fluids through the lymph vessels. This includes wrapping the limb in multiple layers of bandaging, compression garments, specialized massage and other medical equipment geared at restoring the flow of fluids.

Compression treatment is where HME providers come in. However, providing compression garments to lymphedema patients requires some specialized knowledge. To properly provide maintenance for patients with vascular and lymphatic deficiencies, it is important to understand the range of available compression treatment options and which are appropriate for different patients.

Claudia Boyle, medical compression specialist and owner of Van Driel’s Medical Support Wear Co., breaks down compression treatments into the following categories:

• Elastic compression garments (circular and flat knit).
• Short stretch elastic bandages for multi-layer bandaging.
• Non-elastic compression wraps.
• Chopped foam garments.
• Sequential compression pumps.

“For the mildest lymphedema, elastic compression circular knit (often ready to wear) garments are used to manage edema that occurs during daytime hours,” Boyle says. “For more serious conditions, custom-made flat knit products provide more effective support. If the elastic garment successfully manages the lymphedema then often no other treatments are necessary.”

When an elastic stocking or sleeve does not fully manage the condition, Boyle says that nighttime treatments are used to provide additional compression with the goal of reducing limb circumference and breaking down hard fibrotic tissue. Nighttime treatments include multilayer bandaging, chopped foam compression devices and non-elastic compression wraps.

“Multilayer bandaging is used during the active phase of treatment by most physical therapists and is often considered the ‘gold standard’ for maintenance at nighttime, but many patients are unable or unwilling to stay compliant since the process is time consuming and can be difficult to do correctly,” she says. “Patients often prefer to use foam-based nighttime garments or devices for ease of application, and these garments usually do an excellent job of reducing circumferences and breaking down fibrotic tissues.”

Boyle points out that at one time these types of products were primarily custom made but there are now several ready-to-wear, less-expensive options available. Also, non-elastic compression wraps can also be used independently or in addition to elastic compression to support a hard-to-manage leg during the day.

And what are providers eyeing for the future? “The newest products in the market are sequential pumps that do a pre-pumping massage treatment to maximize the effectiveness of the pump,” says Boyle. “Several new Velcro compression wraps have also been introduced recently. There are now many options available to lymphedema patients, making it possible to really customize a treatment program to their individual needs.”

On-Staff Expertise
Along with knowing the different treatment options, providers also need to understand that lymphedema patients require a sensitive, patient, problem-solving staff member who is well-educated on products and is willing to work with the patients to resolve the challenges that many of them present. Boyle says that many lymphedema patients are also cancer survivors who are now facing a new and often unforeseen challenge. They will usually appreciate a compassionate individual who can offer them individualized product options and a sympathetic ear.

“It is extremely helpful to have a compression treatment expert on staff,” says Boyle. “In some regions physical therapists measure and can advise on compression treatments, but in other areas that responsibility falls to the providers. Poorly fit compression treatments can result in angry patients and frustrated staff. It takes time to learn about products, which products to use and when, how to measure tricky patients, etc. There is great benefit in having a well-trained, experienced compression treatment specialist on staff, as well as a private room for consults and fittings.”

Training for compression treatments is usually available from product manufacturers. Elastic compression stockings, particularly the custom-made products, require the greatest amount of training, says Boyle. Training classes are usually one day events held at various locations around the country, and can be repeated to increase fitting proficiency and product knowledge. Along with companies, some schools, such as The Norton School, offer courses and certification.

Possible Funding Changes?
Finally, providers should understand how Medicare affects their patients, but this is no easy task. HME Business magazine called on Robert Weiss, a lymphedema patient advocate and noted industry expert on the subject. He is the Insurance and Legislation Chair for the National Lymphedema Network, and has a regular column in its quarterly newsletter, LymphLink. Weiss is a volunteer and receives no compensation from any company, foundation or private source.

“Compression bandage systems, compression garments and compression devices used in the treatment of lymphedema are denied by Medicare in spite of their being covered statutorily by §1861(s)(8) of the Social Security Act as interpreted by §120 of the Medicare Benefit Coverage Manual, CMS Pub. 100-02, Chapter 15 as prosthetic devices,” says Weiss. “Pneumatic compression devices (pumps) are covered if referred by a Medicare-enrolled physician and provided by a Medicare-enrolled supplier. Special documentation includes a Certificate of Medical Necessity CMS-846 — Pneumatic Compression Devices and certification that the patient has undergone ‘conservative’ treatment (elevation, compression, exercise) for four weeks and that there has been no improvement or has been deteriorization.”

Weiss notes that compression garments are allowed in the treatment of burns, wounds and as secondary surgical dressings under §1861(s)(5). They are denied as DME since they do not meet the “rentability” coverage requirement in §1861(n) even though they do meet the DME coverage requirements of §1861(s)(6).

“It takes a minimum of two years (increasing lately because of ALJ loads) to appeal the denial of a compression garment used in the treatment of lymphedema,” says Weiss. “Approximately 60 percent of the Medicare denials are reversed by the ALJ when presented with the medico-legal arguments, which show that compression materials meet the Medicare coverage criteria for prosthetic devices.”

The current HCPCS Codes do not adequately cover the range of items used in the treatment of lymphedema, and the result is that a medically required custom garment is reimbursed to a schedule for an off-the-shelf garment at a fraction of the cost of the required garment, says Weiss.

Weiss supports Representative Rep. Larry Kissell’s (D-N.C.) Lymphedema Diagnosis and Treatment Cost Saving Act of 2010 (H.R. 4662), which strives to provide quality treatment to lymphedema patients and saving Medicare hundreds of millions of dollars per year in avoided lymphedema-related cellulitis treatment.

This article originally appeared in the September 2010 issue of HME Business.