Coverage of lymphedema diagnosis and treatment services under Medicare

(a)

Coverage of services

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended— (1)in subsection (s)(2)— (A)in subparagraph (EE), by striking and at the end; (B)in subparagraph (FF), by adding and at the end; and (C)by adding at the end the following new subparagraph:

(GG)(i)lymphedema diagnosis services (as defined in subsection (iii)(1)) and lymphedema treatment services (as described in subsection (iii)(2)); and (ii)lymphedema compression treatment items (as defined in subsection (jjj)).

; and

(2)by adding at the end the following new subsections:

(iii)

Lymphedema diagnosis and treatment services

(1)

Lymphedema diagnosis services

The term lymphedema diagnosis services means, with respect to an individual, the differential diagnosis of the source of the individual’s edema and the identification of the specific etiology and functional lymphatic deficiency, in which such diagnosis— (A)is provided by a provider, as defined in paragraph (3), for the purpose of developing a lymphedema treatment plan; and (B)may utilize any diagnostic tools the provider determines to be reasonable and necessary. (2)

Lymphedema treatment services

The term lymphedema treatment services means, with respect to an individual, services for the treatment of lymphedema (regardless of cause)— (A)that are— (i)provided in an inpatient or outpatient setting; (ii)provided by a provider, as defined in paragraph (3), within the established scope of practice of such provider; and (iii)medically necessary, in accordance with the current standard of lymphedema treatment, including complete decongestive therapy, which is a multi-modal therapy comprising of manual lymph drainage, compression therapy utilizing multilayer bandage systems, compression garments and devices, exercise, skin care, patient education, and any other lymphedema treatment modalities determined by the Secretary to be safe and effective; and (B)which shall— (i)include as medically necessary with respect to the individual— (I)an initial evaluation and course of clinical treatment, including initial baseline measurements and subsequent measurements to assess treatment efficacy and progress; (II)follow-up courses of clinical treatment; (III)in the case that such individual has cancer, clinical measurements, including initial pre-operative baseline measurements and periodic subsequent measurements to diagnose the presence of lymphedema; and (IV)any other treatment modality approved by the Secretary; and (ii)be provided in accordance with such schedule, duration, and number of treatments as determined medically necessary. (3)

Provider defined

For purposes of this subsection and subsection (jjj), the term provider means any licensed medical or health care provider whose State licensing board recognizes lymphedema diagnosis, lymphedema treatment, or both to fall within the scope of practice of such medical or health care provider. (jjj)

Lymphedema compression treatment items

The term lymphedema compression treatment items means, with respect to an individual, compression garments, devices, bandaging systems, components, and supplies that are primarily and customarily used in the medical treatment of lymphedema of the arms, hands, legs, feet, torso, face and neck, breast and chest, abdomen, and genitalia, as prescribed by a provider, as defined in subsection (iii)(3). Such term includes— (1)multilayer compression bandaging systems, including short-stretch and medium-stretch compression bandages; cotton, synthetic, or foam padding; gauze or elastic finger and toe bandages; foam pads; directional flow padding; and tubular bandages; (2)custom or standard fit gradient compression garments; (3)non-elastic and low-elastic compression garments, manually adjustable or fitted padded directional flow garments (with or without elastic or non-elastic compression jackets) and compression wraps and directional flow pads; (4)aids and ancillary equipment consisting of donning aids, bandage rollers, shoes to fit over compression items, and other specialized items used with the items described in paragraphs (1) through (3); (5)pneumatic appliances connected to and used in conjunction with pneumatic sequential compression controllers; (6)any other compression garments, bandaging systems, devices, and aids determined by the Secretary to be effective in the prevention or treatment of lymphedema; and (7)replacements of any items under this subsection in accordance with section 1834(p)(3).

(b)

Payment

(1)

Lymphedema compression treatment items

(A)

In general

Section 1833(a) of such Act (42 U.S.C. 1395l(a)) is amended— (i)in paragraph (8), by striking at the end and; (ii)in paragraph (9), by striking at the end the period and inserting a semi-colon; and (iii)by adding at the end the following new paragraph:

(10)in the case of lymphedema compression treatment items described in section 1861(jjj), the amount determined under section 1834(p); and

(B)

Payment determined

Section 1834 of such Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(p)

Payment for lymphedema compression treatment items

(1)

General rule for payment

(A)

In general

With respect to a lymphedema compression treatment item as defined in section 1861(jjj)) for which payment is determined under this subsection, subject to subparagraph (D), payment shall be made in an amount equal to 80 percent of the payment basis described in subparagraph (B). (B)

Payment basis

The payment basis described in this subparagraph, with respect to a lymphedema compression treatment item described in section 1861(jjj), is the actual charge for the item. (C)

Exclusive payment rule for home health agencies

Notwithstanding any other provision of this title, this subsection shall constitute the exclusive provision of this title for payment for lymphedema compression treatment items described in section 1861(jjj) under this part or under part A to a home health agency or for such items that are furnished as an incident to a physician’s professional service. (2)

Allowable quantities

In the case it is determined by a provider, as defined in section 1861(iii)(3), that lymphedema compression treatment items are required as part of lymphedema treatment services under section 1861(iii)(2), then payment may be made under this title in accordance with this subsection for such items in the quantity which is customary, reasonable, and medically necessary. (3)

Replacement of lymphedema compression treatment items

(A)

In general

Payment shall be made under this subsection, with respect to an individual, for the replacement of a lymphedema compression treatment item if the period of the reasonable and useful lifetime of the item (as described in subparagraph (B)) has expired or a provider, as defined in section 1861(iii)(3), determines that a replacement, or repair, of such item, is medically necessary. (B)

Reasonable and useful lifetime

For purposes of subparagraph (A), the period of the reasonable and useful lifetime of a lymphedema compression treatment item is as follows: (i)In the case of any item described in section 1861(jjj)(1), 1 year. (ii)In the case of any item described in section 1861(jjj)(2), 6 months. (iii)In the case of any item described in section 1861(jjj)(3), 2 years. (iv)In the case of any item described in section 1861(jjj)(4), 1 year. (v)In the case of any item described in section 1861(jjj)(5), 5 years. (vi)In the case of any item described in section 1861(jjj)(6), such period as determined by the Secretary, in consultation with appropriate health organizations, at the time the Secretary determines such item to be effective in the prevention or treatment of lymphedema.

(C)

Application of supplier requirements

Section 1834(j)(5) of such Act (42 U.S.C. 1395m(j)(5)) is amended— (i)in subparagraph (E), by striking at the end and; (ii)in subparagraph (F), by striking at the end the period and inserting ; and; and (iii)by adding at the end the following new subparagraph:

(G)lymphedema compression treatment items (as defined in section 1861(jjj)).

(2)

Lymphedema diagnosis and treatment services

(A)

In general

Section 1833(a) of such Act, as amended by paragraph (1)(A), is further amended by adding at the end the following new paragraph:

(11)(A)in the case of lymphedema diagnosis services (as defined in section 1861(iii)(1)) furnished by a provider (as defined in section 1861(iii)(3)) the amount described in section 1834(q); and (B)in the case of lymphedema treatment services (as defined in section 1861(iii)(2)) furnished by a provider (as defined in section 1861(iii)(3)) the amount described in section 1834(k).

(B)

Payment method

Section 1834 of such Act, as amended by paragraph (1)(B), is further amended by adding at the end the following new subsection:

(q)

Payment for outpatient lymphedema diagnosis and treatment services by physicians and non-Physician practitioners

(1)

In general

For purposes of section 1833(a)(11), the amount described in this subsection, with respect to a lymphedema diagnosis service or lymphedema treatment service, is 80 percent of the lesser of— (A)the actual charge for the service; or (B)the applicable fee schedule amount (as defined in paragraph (2)) for the service. (2)

Applicable fee schedule amount

In this subsection, the term applicable fee schedule amount means, with respect to services furnished in a year, the amount determined under the fee schedule established under section 1848 for such services furnished during the year.

(C)

Conforming amendment for payments under 1834(k)

Section 1834(k)(1) of such Act (42 U.S.C. 1395m(k)(1)) is amended by striking or 1833(a)(9) and inserting 1833(a)(9), or 1833(a)(11). (c)

Effective date

The amendments made by this section shall apply to items and services furnished on or after the date that is 180 days from the date of the enactment of this Act.