Manual lymphedema drainage (MLD) therapy consists of education, skin care, massage, containment wrapping, exercise and supportive garments.  Manual lymphedema drainage is eligible when the following conditions are met:

• There is a physician documented diagnosis of lymphedema (457.0, 457.1, 757.0)
• The patient is symptomatic for lymphedema, with limitation of function.
• The patient or patient caregiver has the ability to understand and comply with home care continuation of the treatment regimen.
• The services are being performed by a physician and/or licensed physical therapist who has received specialized training in this form of treatment.

Manual lymphedema drainage therapy is designed to transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient family or patient caregiver.  It is expected that physician/physical therapist treatment would only last for one to two weeks, depending on the progress of the therapy.  After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting.  The maximum benefits of treatment cannot be achieved unless the patient continues treatment at home.

There are currently no codes available for reporting a comprehensive program of therapy; however, the components of MLD can be reported as physical medicine or evaluation and management services.  MLD services are eligible for one hour sessions, three times per week for two weeks.  

Physical Medicine Services
Report the physical medicine portion of MLD using codes 97140 or S8950:

Physical medicine services are subject to all physical medicine guidelines as stated in Medical
Policy Bulletin Y-1, Physical Medicine).

Evaluation and Management Services
Other services, such as education and skin care, are part of medically necessary evaluation and management services.  Use procedure codes 99201-99215 to report the appropriate evaluation and management service.  It is not appropriate to bill an evaluation and management service each time a patient receives a physical medicine treatment, procedure code 97140 or S8950.  An evaluation and management service should not be billed unless all of the components of the visit have been met.

Repeat Services
When physician treatment of lymphedema using MLT or complete decongestion physiotherapy (CDP) exceeds two weeks, documentation should accompany the request for those services to substantiate the medical necessity of continuation of the treatment.  Services that do not meet the medical necessity guidelines are considered not medically necessary.  Participating, preferred, or network providers cannot bill the member for the denied service.

A patient may require “tune up” lymphedema decongestant massages after minor events (e.g., local infection, trauma, therapeutic injections).  With these subsequent treatments, the same criteria as that of initial treatment must be met. 

Maintenance Services
MLT or CDP performed repetitively to prevent regression is considered maintenance and is not eligible for payment.  A participating, preferred, or network provider can bill the member for the denied service.

Lymphedema Pump
Treatment of lymphedema using a lymphedema pump is also considered an eligible service.  It is not expected that a patient using a pump would also require MLD.  (See Medical Policy Bulletin E-7, Intermittent Compression Pumps, for additional information.)

Documentation Requirements
Medical record documentation to support medical necessity should be maintained in the medical record and be available upon request.  This documentation should include:

• Physician documented diagnosis of lymphedema (457.0, 457.1, 757.0)
• A statement as to the ability of the patient/patient caregiver to follow through with the continuation of treatment on a long-term home treatment plan.
• The medical necessity of each treatment.
• History and physical which addresses the cause of the lymphedema and any prior treatment.  It must also address the symptoms which necessitate treatment.
• Measurement of body part/extremity prior to treatment.
• A report showing the progress of the therapy which should contain measurements showing a reduction in size of the extremity.  This should also address the response of the patient/patient caregiver to the education and their understanding and ability to take on some of the responsibilities of the treatment.  This progress report must also address the expected outcome of the treatment as well as the expected duration of treatment.

Coverage is subject to any applicable physical medicine and/or office visit limitation in the individual member’s or group member’s benefit contract.  Participating, preferred, and network providers can bill the member for denied services that exceed the member’s benefit limitations.

Description
Lymphedema occurs when the lymph flow from an extremity is compromised because of obstructed or inadequate lymphatic vessels. Noninvasive complex lymphedema therapy is referred to by several terms including: early conservative lymphedema management, complicated physiotherapeutic, multi-modal lymphedema therapy, palliative lymphedema therapy, manual lymphedema treatment (MLT) and complete decongestive physiotherapy (CDP).

MCM 2050.2, 2200, 2210, 2215, 2480, 4160
MCIM 60-16