Sharon Furr LPN, CCT
Cell: 941-623-2810 Fax: 888-322-7922
Physician Requirements per Medicare for Lymphedema
Pump & Sleeves Upper and Lower Extremity Lymphedema
- Physician determines if the patient qualifies
- Patient must have seen their doctor within the last 6months. Doctor needs to have charted that he suspects the patient has Lymphedema and include the Pt’s prognosis.
- The physician needs to have ordered a combination of the following conservative treatments consisting of wraps (required), elevation, physical therapy, massage and/or diuretics to rule out other causes.
- The physician needs to write an order for evaluation of patient for pumps/sleeves and send to DME Company as a Detailed Written Order. (See criteria for DWO below)
- The physician needs to have charted that the patient underwent 4 consecutive weeks of conservative therapy by a medical professional without positive clinical outcome
- The patient must have undergone surgery and/or radiation that compromised the lymphatic system OR have a congenital condition that is related to lymphedema
- Symptoms and objective findings, including measurements which establish the severity of the condition;
- The physician must have the above documented in the Pt’s chart.
- Physician Order
- The attending physician must provide the detailed written order which specifies all of the following:
- The type of intermittent compression therapy device
- The type of garment (half arm, full arm, half leg, full leg)
- The pressure for therapy in mmHg
- The duration in minutes per treatment session (30 -120 minutes/session)
- The frequency per day of the treatment (example: 2 sessions per day)
- Length of need for the treatment
- Quantity of each item to be dispensed
- Beneficiary’s Name
- Physician’s Printed Name
- Physician’s NPI
- Physician’s signature and date
- Certificate of Medical Necessity (CMN) form - required by Medicare
- Physician must fill out Section B of the attached CMN
- Physician must sign and date Section D of the attached CMN.