Lymphedema Compression Garments - DME.SU.102.A

Medically necessary lymphedema compression garments (gradient compression garments/wraps and related compression bandaging supplies) for upper or lower extremity lymphedema are covered, with custom-fitted garments allowed only when basic coverage criteria are met and documentation shows off‑the‑shelf garments are inadequate. Coverage limits three daytime garments per affected extremity every 6 months and two nighttime garments every 2 years; replacements are allowed only for loss/theft, irreparable damage, or clinical change, and documentation is required for diagnosis, medical necessity, justification for custom fit, and any replacement.

"A lymphedema compression garment is considered medically necessary for the treatment of upper or lower extremity lymphedema."

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