93702
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$132.60
Non-Facility
$132.60
Documentation Required
- Sutherland et al (2021): BIS measurements before any oncologic surgery (baseline) and serial BIS during follow-up office visits including before and after LVB -- documentation of serial BIS for pre/post procedure assessment.
- FLLA-LVSP technique: use of indocyanine green (ICG) fluorescent dye and Blue Patent Violet dye injected laterally/medially to visualize superficial lymphatic network and sketch onto skin prior to surgery -- documentation of intraoperative lymphatic mapping and volumes removed (circumferential measurements and frustum formula).
- Diagnosis of lymphedema must be documented in the medical record.
- For pneumatic compression device (non-calibrated) coverage: documentation of persistence of chronic and severe lymphedema by at least one of the listed clinical findings (marked hyperkeratosis with hyperplasia and hyperpigmentation; papillomatosis cutis lymphostatica; deformity of elephantiasis; skin breakdown with persisting lymphorrhea) OR detailed measurements over time confirming persistence of lymphedema with history evidencing likely etiology.
Key Coverage Criteria
- Complex Decongestive Physiotherapy (CDP) is medically necessary when BOTH of the following are met: (1) the member has ANY of the following: evidence of ulceration due to lymphedema; OR intractable lymphedema of the extremities unrelieved by elevation; OR one or more previous admissions to treat complications of intractable lymphedema (e.g., cellulitis, ulceration); AND (2) the member has shown a past record of compliance and the member or caregiver is capable of following the instructions assoc [...]
- Home use of a non-segmented (unicompartmental) device or segmented (multicompartmental) pneumatic compression device WITHOUT manual control of the pressure in each chamber (E0650/E0651-style devices) is medically necessary for members with chronic and severe lymphedema when ALL of the following are met: (a) member has a diagnosis of lymphedema; (b) persistence of chronic and severe lymphedema documented by at least one clinical finding: marked hyperkeratosis with hyperplasia and hyperpigmentatio [...]
- Home use of a segmented pneumatic compression device WITH calibrated gradient pressure (segmented device with manual control of pressure in each chamber; e.g., E0652) is medically necessary for treatment of lymphedema extending onto the chest, trunk and/or abdomen when ALL of the following are met: (a) member has diagnosis of lymphedema; (b) member meets medical necessity criteria for a pneumatic compression device as above; AND (c) lymphedema extends onto chest/trunk/abdomen past limits of a st [...]
- Static compression sleeves (e.g., ReidSleeve, ArmAssist) are medically necessary supplies for members with intractable lymphedema of the arms.
- Excisional procedures (debulking, liposuction, suction-assisted protein lipectomy) are medically necessary for treatment of chronic refractory lymphedema.
- Covered ICD-10 diagnoses (when selection criteria are met) include: I89.0 - I89.9 (other noninfective disorders of lymphatic vessels and lymph nodes [intractable lymphedema] [secondary lymphedema]); I97.2 (postmastectomy lymphedema syndrome); Q82.0 (hereditary lymphedema).
8 Active Policies
AETNA-CPB-0069 — Lymphedema
HUMANA-LYMPHEDEMA-DIAGNOSIS-AND-TREATMENT-MA — Lymphedema - Diagnosis and Treatment - Medicare Advantage
BCBSIL-MED201.036 — Bioimpedance Devices for Detection and Management of Lymphedema
BCBSMT-MED201.036 — Bioimpedance Devices for Detection and Management of Lymphedema
BCBSNM-MED201.036 — Bioimpedance Devices for Detection and Management of Lymphedema
Related Codes
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