Lymphedema is a chronic condition characterized by swelling, typically in the arms or legs, that results from a failure or obstruction in the lymphatic system to properly drain fluid. This impairment causes protein-rich fluid to accumulate in the tissues, leading to noticeable enlargement of the affected body part. To manage this condition, compression garments are prescribed to apply controlled pressure, which helps to move the fluid and prevent further swelling. These specialized garments are a necessary component of ongoing lymphedema treatment, helping to reduce symptoms and maintain the limb size achieved through therapy.
The Definitive Medicare Coverage Change
For many years, Medicare coverage for lymphedema compression supplies was not available because the items did not fit into an existing benefit category. This lack of coverage meant that patients often had to pay the entire cost for these medically necessary garments out of pocket. The situation changed definitively with the passage of the Lymphedema Treatment Act, which was signed into law in late 2022.
The legislation created a new Medicare benefit category specifically for lymphedema compression treatment items. This landmark policy became effective on January 1, 2024, finally providing coverage for these supplies. The Act essentially classified lymphedema compression treatment items under Medicare Part B, which covers certain doctor’s services, outpatient care, and medical supplies. This new coverage standardizes payment for these items, significantly improving access for Medicare beneficiaries with a lymphedema diagnosis.
Which Lymphedema Garments Are Covered
Medicare’s expanded coverage includes a broad range of compression supplies, encompassing both garments for daily wear and systems used in intensive treatment phases. The benefit covers standard, ready-to-wear compression garments as well as custom-fitted garments, both for daytime and nighttime use, provided they are medically necessary. Custom-fitted garments are designed to match the unique size and shape of an individual’s affected limb, which is often needed when the limb has significant size differences or unusual contours.
The coverage also includes compression bandaging systems and supplies. These bandaging items are covered for both the initial decongestion phase, where swelling is actively reduced, and the long-term maintenance phase. Gradient compression wraps with adjustable straps are also covered, which allow patients to self-adjust the pressure. Furthermore, accessories necessary for the effective use of these items, such as aids for putting the garments on or taking them off, special linings, padding, and zippers, are also included in the coverage.
Navigating the Coverage Requirements
To receive coverage for lymphedema compression supplies, a patient must meet specific administrative and medical criteria under Medicare Part B. The first requirement is a diagnosis of lymphedema, and the items must be used primarily to treat the symptoms of that condition. A medical practitioner, such as a physician, physician assistant, nurse practitioner, or clinical nurse specialist, must prescribe the compression items. This practitioner’s prescription serves as the certification of medical necessity, confirming the required type, quantity, and frequency of the items.
Patients must obtain the prescribed garments and supplies from a supplier that is enrolled with Medicare as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier. The payment made to the DMEPOS supplier is a bundled rate that includes the cost of the item, along with any necessary fitting, measurement, and patient education on how to properly use the garments. Medicare Advantage Plans, known as Part C, must also cover the same items as Original Medicare (Part B), although they may have specific requirements like using in-network suppliers or obtaining prior authorization.
Patient Costs and Replacement Limits
For beneficiaries with Original Medicare Part B, the coverage for lymphedema compression items follows the standard cost-sharing rules. After the annual Part B deductible has been met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for the supplies. The remaining 80% is paid by Medicare.
Medicare has established clear frequency limitations for replacing the compression garments, which are based on the type of garment and the body part affected. For daytime compression garments or wraps, Medicare covers up to three complete garments per affected body part every six months. Nighttime garments have a different replacement schedule, with coverage for up to two garments per affected body part every two years. A new set of garments is also covered if they are lost, stolen, irreparably damaged, or if a change in the patient’s medical condition warrants a new size or type of garment.