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CVI and Lymphedema Patient Bill of Rights - Part II - Page 3

© Linda Bily

Insurers must contract with, and/or require provider's who are providing treatment, supplies, and equipment for patients only through provider's who are trained, and knowledgeable in vascular and lymphatic diseases. Insurers shall require and reimburse provider's, including DME lymphatic and vascular specialists who are able to properly evaluate a patient's needs, provide home set-up and instruction on supplies, or equipment provided, educate the patient on the application of treatment, supplies, and equipment, conduct pre-treatment, and post-treatment measurements, and provide at least one follow-up visit including measurements and documenting improvement after treatment has been used for four to six weeks based on patient availability. Insurers shall require providers to submit policy and procedure of outlining education and experience specific to lymphatic and vascular disease, set-up, and follow-up procedures to insurer with contract and/or prior authorization request and/or claim submission. Insurer's must provide reimbursement to DME providers for a Certified Compression Therapist's evaluation, set-up procedures and patient education, and follow-up evaluations, as ordered by the treating physician.

An insurer may not "bundle" reimbursement for physical therapy, application of MLD/CDP, and application of external compression with physical therapy as treatment for other rehabilitation, or diagnoses. Insurer's must cover but not require MLD/CDP therapy if a patient is not able to attend therapy due to a physical inability, excessive employment schedule or other inhibiting factors, in order to cover DME home medical equipment.

Insurer's may not allow the shipping of sequential compression pumps, external mechanical compression therapy, or gradient calibrated sequential compression pumps, except when item is a replacement item, but must require home set-up, hospital or rehab facility set-up, measurement and education procedures as outlined herein, by a Certified Compression Therapist. These devices may not be set-up by a Certified Lymphedema Therapist unless no Certified Compression therapist is available in the beneficiary's area.

Insurer's must change policies, procedures, plan benefits, reimbursement codes, allowable, reasonable and customary fees and contracts with providers to be in compliance with this law, and may not engage in contracted fees and allowable or reimbursement for any amount less than Medicare's allowable, unless an early payment discount has been negotiated. Insurer's may not at any time for any reason, change the plan of treatment or the prescribed treatment as ordered by the treating physician, by denying coverage for ordered treatment, supplies, or equipment and requiring, recommending, or otherwise offering other alternatives for treatment, but shall approve recommended treatment exactly, without any such variation of the prescription as written by the ordering physician. Any person(s) or company who engage in such activity will be criminally and legally subject to prosecution under federal and state insurance and medical malpractice laws, as well as financially responsible for any damages caused by this action.

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