HCFA Agrees to Pay for Lymphedema Treatment
A group of physicians successfully lobby for lymphedema treatment in Florida
By Mike Le Postollec
Therapists and other health professionals pushed to the brink of exhaustion by Medicare's sometimes perplexing reimbursement policies and bureaucratic red tape might be tempted to throw up their hands in defeat and despondently mutter, "You just can't beat the system." But don't tell that to Robert Lerner, MD, FACS, medical director of Lerner Lymphedema Services PC, a network of facilities exclusively dedicated to the treatment of lymphedema and the education of physicians, PTs, OTs and massage therapists who deal with the condition. Dr. Lerner has fought the uphill battle for reimbursement in the state of Florida, and is all too familiar with the hassles that it can entail.
"When we first opened [a center] in Florida, in the mid-1990s, we began treating patients for lymphedema using the Complete Decongestive Physiotherapy (CDP) method, and there was no reimbursement for the treatment," Dr. Lerner explained. "No one even understood the method we were talking about, including the Medicare intermediary." Nonetheless, after years of negotiation, debate and a great deal of time and effort on the part of Dr. Lerner and other concerned providers in the state, Florida Blue Cross/Blue Shield (the state's Medicare intermediary) agreed to a compromise: 10 reimbursable visits for CDP treatment each year. And even though Dr. Lerner noted this number of visits may not be all that's needed for some patients, it could lend hope to other professionals lobbying to get their patients the treatment they need.
Lymphedema Treatment and CDP
Although lymphedema treatment using pneumatic pumps and a variety of surgeries have been available for many years, an effective, noninvasive and clearly defined approach to the treatment of lymphedema is a fairly new phenomenon stateside. While those two options (pumps and surgery) have always been reimbursable treatments in all states and under most health care plans, alternate forms of treatment were never truly considered by most payers. "Florida Medicare always reimbursed for the pneumatic pump and for surgery," said Dr. Lerner. "If a patient was hospitalized for surgery or for a complication of lymphedema, and there are many, then Medicare would reimburse for it. But those were the only two options they would pay for."
Meanwhile, therapists at Dr. Lerner's Fort Lauderdale, FL, branch of Lerner Lympedema Services had been practicing a third option, CDP, since the facility opened in 1994. Based on a European model that dates back to 1892 Berlin, CDP is comprised of four treatment components:
* Meticulous skin and nail care, including the eradication of any infection with antimicrobial therapy
* Manual lymph drainage, which prompts the lymph fluid to flow faster and with greater force. "If you watch someone doing this, it might look like massage, but it's much more delicate and it only stimulates the lymph vessels to do much more work," Dr. Lerner explained.
* Multi-layered compression bandaging, using nonelastic bandages
* Remedial exercises, performed while the patient is bandaged.
If this protocol is followed carefully, and followed up with a four-step patient self-maintenance program, Dr. Lerner said, the patient will notice an improvement of the condition after one session, and should see "wonderful results" within one week of therapy.
This protocol has been a staple of Lerner Lymphatic Services since 1989. But while Dr. Lerner experienced no difficulties with Medicare reimbursement at the company's three other facilities, Florida simply wasn't buying. "Before we opened our facility in Boston, we questioned Medicare, explained what CDP was and which codes we would use, and there was no problem," he recalled. "In New York there was no problem, and in New Brunswick, NJ, there was no problem. But Medicare [in Florida] said they wouldn't pay for it."
"Before we went to Florida, we had been in contact with the American Medical Association's reimbursement department, and we asked them how we should go about billing for what we do in the state, and they said that we should use the physical therapy CPT codes, which were already in existence and are the closest thing to [CDP]," Dr. Lerner added.
Despite the existing policy in the state, Dr. Lerner and other Florida physicians were certain of CDP's benefits, and were determined to express their point to Medicare. During the year following Lerner Lymphedema Service's Fort Lauderdale opening, Dr. Lerner contacted Medicare on a number of occasions, and, after engaging a law firm, managed to negotiate a meeting with its intermediary, Blue Cross/Blue Shield of Florida, to discuss the treatment. "It was basically a discussion of CDP, how it's performed, who does it, and many before and after photos to show that the patients do get better, there's no risk, no surgery and nothing dangerous involved with the treatment," he said. "And I explained that we don't cure patients with CDP; we reduce the swelling and teach the patient to keep the swelling from recurring [by continuing] a maintenance program at home, which they continue forever after therapy.
"But after my presentation they still said that what we were doing was not medically necessary and they refused to reimburse for it. And I don't think there was a medical reason for [their conclusion]; they were trying to save costs, and that's still what drives Medicare."
Fortunately, Dr. Lerner was not alone in his efforts. Other concerned therapists and physicians in Florida, such as John Macdonald, MD, FACS, thoracic vascular surgeon and medical director of the Wound Healing Lymphedema Center, Fort Lauderdale, were equally sold on CDP's efficacy, and were ready to pursue negotiations with Medicare. "My wife and I have been very involved in working with patients in Haiti, and for the past two or three years, we became involved in a clinic in a town called Leogane, which is south of Port-au-Prince, where the Center for Disease Control and Prevention, Atlanta, had instituted a program for the area, which is endemic for elephantiasis," said Dr. Macdonald. "The Center was using CDP in treating these patients for severe lymphedema and even in limited conditions they were doing extremely well."
Convinced by this firsthand experience, Dr. Macdonald began spreading the word to a number of MDs in Florida who were involved in oncology, vascular surgery, physiatry and other related fields, and with their involvement helped develop a CDP protocol. The new protocol, based on physical therapy CPT codes with MD and OT involvement, is essentially a quicker (10 visits over two week) version of the European model, adapted to the time and money restraints of the U.S. health care system by a stronger focus on patient education and self-management.
Detractors may call this a compromise, but the fact is, the model was submitted to Blue Cross/Blue Shield of Florida, and approved on Oct. 20, 1997. Under the accepted model, Florida Medicare will now reimburse up to 10 CDP treatments (documented under pre-existing PT and OT codes) per year. Moreover, Dr. Macdonald added, the method works.
"We're now finding that 80 percent of the patients we're treating have excellent results within two weeks, and for people with severe lymphedema, we may have to apply for extensions, but overall we feel that this new system is more economical, and the results are dramatic," he said.
The Next Step
While this course of events is encouraging, those who treat lymphedema using the CDP method are quick to point out that their work is not yet complete. For one thing, there is no standardized certification in place, so at the present time nearly any health professional can claim to deliver and bill for the treatment. By European standards, approximately 135 to 140 hours of experience sufficiently "certifies" the practitioner, and the hope is that the handful of CDP practicing schools in the United States will eventually be responsible for certifying therapists in the method. The Lerner Lymphedema Services Academy of Lymphatic Studies in Fort Lauderdale and the Vodder School in Austria already give certifying course in the CDP method of treatment, according to Dr. Lerner.
And then there is the matter of simply educating the health care community on CDP's potential benefits, and making the treatment available (not to mention reimbursable) nationwide. "We want to get this information out, and we want to get the Florida protocol out there so that it can be established and accepted in other jurisdictions," Dr. Macdonald concluded. "There are literally thousands of Medicare patients with lymphedema who have no access to any care at all unless they pay for it [out of pocket], and our goal here is to share this treatment with the patients who need it." *
Mike Le Postollec is on staff at ADVANCE.