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Outpatient Therapy Caps Exception Process 2007

PostPosted: Sat Feb 03, 2007 5:40 pm
by patoco
Outpatient Therapy Caps Exception Process 2007

The process by which exceptions are obtained for exceeding the $1780 annual limit to physical and speech therapy and occupational therapy have been published. The following is a URL for California and other states covered by NHIC Medicare Contractor. I assume that the Medicare Part B Contractors have or will issue similar direction for their regions. ... t_0107.htm

CMS has taken another step relating to lymphedema treatment making it more difficult for Medicare "Beneficiaries" to receive care according to current treatment guidelines. In 2006, lymphedema (ICD-9-CM diagnostic codes 457.0- postmastectomy LE and 457.1- other LE) treatment was automatically excepted from the annual $1740 limit. This year the exception is only afforded if a second co-diagnosis is shown "that MIGHT cause medically necessary therapy services to qualify for the automatic process exception for each discipline separately".

Both ICD-9's must be shown on the claim. "In most cases, the severity of the condition, comorbidities, or complexities will contribute to the necessity of services exceeding the cap, and these should be documented." The annual limit has been raised to $1780 for 2007.

I have heard already (and it is only January) of one case where a lymphedema patient was told that she has already received the limit of her treatment, and cannot receive any more. Please do not ask me to interpret the policy, or which co-morbidities might qualify as "complexities" that would justify exceptiion to the cap. I am not qualified or authorized to make those determinations. I would, however, like to keep track of any experiences relating to exceeding the limits, and how they were handled.

The situation on Medicare lymphedema treatment coverage gets worse each year. In March 2005 CMS changed their interpretation of the Social Security Act to limit coverage of manual lymph drainage to physical and occupational therapists, thereby eliminating coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists. This effectively reduced the number of available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced
to close as a result of this policy change.

And in March 2006 CMS re-coded the compression garments which are the
mainstay of lymphedema treatment from prosthetics (the benefit category covering compression garments for lymphedema) to surgical bandages (a benefit category which is not covered in a home setting). This effectively denies the millions of lymphedema Medicare beneficiaries coverage of the treatment which they require every day for the rest of their lives.

Please contact your Congressional representatives. Urge them to sponsor and support bills which will correct these limitations to access to proper
lymphedema treatment. I will be in Washington in early May and will follow up on your letter, and leave an information package with your Congressional representative on your behalf. The package will include a proposed "lymphedema Diagnosis and Treatment Cost Saving Bill" which will address these issues.

Just send me a copy of the letter you write.


Bob Weiss

Robert Weiss, M.S.
Lymphedema Treatment Advocate


Pat O'Connor
Lymphedema People