Lymphedema Requirements

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Unity Medical

Unity Medical

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.

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