CVI

CVI and Lymphedema Patient Rights Bill

Part One

Pages One through Four

As Written By: Cheri Hoskins (Healthtronix) and Cyndi Ortiz (Nevada Lymphatic and Cascular)

10/30/04

Definitions:

“Health Insurer” means any company, organization, private entity, self-funded entity, or government agency (Medicare and Medicaid and administrators thereof), health maintenance organizations, and private insurance companies contracted to provide health care coverage for Medicare recipients, Veterans Administration, United States Military, CHAMPUS or any entity that provides or represents itself as providing assistance for coverage for health care expenses.

“Lymphedema” means a disease in which the lymph system is not functioning correctly or is blocked, causing one or more parts of the body to become chronically edematous. This law defines Lymphedema as being caused by a congenital or hereditary defect, removal of lymph nodes, surgical interruption, radiation, or unknown cause.

“Chronic”. This law defines chronic as one or more signs or symptoms, edema, hyperpigmentation, or wounds, being present for six months or more.

“Chronic Venous Insufficiency” means a disease of the veins in which blood return to the heart is not sufficient. This law lists the symptoms of venous insufficiency as chronic edema, hyperpigmentation, stasis dermatitis, and pain.

“Peripheral Vascular Disease” means an abnormal condition of the blood vessels outside the heart and lymph vessels. This law lists the symptoms of peripheral vascular disease as numbness, pain, hyperpigmentation, elevated blood pressure, and impaired arterial pulsations.

“External Compression” means various forms of external compression modalities.

“Manual Lymph Drainage or MLD” means manipulative physical therapy technique that assists in opening pathways for lymph to flow.

“Combined Decongestive Therapy or “CDT” means and or includes manual lymph drainage, gradient bandaging, remedial exercises, circumferential measurements, nutritional instructions, and instructions on proper skin care.

“Certified Lymphedema Therapists” means a licensed physical therapist, occupational therapist, message therapist, registered nurse, or licensed practical/vocational nurse who has received at least 135 hours of training specific to lymphatic and vascular disease, manual lymph drainage, and combined decongestive therapy by an independent certification entity or agency.

"Treating Physician" A Physcian or Medical Doctor, Physician's Assistant, or Podiatrist who is treating the patient for lymphatic and/or vascular disease.

“Provider” means a provider of therapy, supplies, and equipment.

“DME Provider” means a provider of durable medical equipment.

“Patient” means a person, male or female, who has been diagnosed by a physician upon physical examination with chronic venous insufficiency, lymphedema, or peripheral vascular disease.

“Treatment” means effectively treating lymphedema, chronic venous insufficiency, and peripheral vascular disease utilizing available treatment and management modalities as recommended by the treating physician.

“Disease Management ” means effectively managing lymphedema, chronic venous insufficiency, and peripheral vascular disease, utilizing available treatment and management modalities as recommended by the treating physician, in such a way that will create patient independence, and treatment success.

“Specialize or Specialty” means a person or company or health care entity whose primary function is offering treatment, supplies, or equipment specific to chronic venous insufficiency, lymphedema, or chronic venous insufficiency.

“Home Disease Management Program ” means a disease management program, specific to each patient’s needs, that will ensure that a patient is able to successfully treat and manage their disease independently at home for the remainder of their life.

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“Certified Compression Therapist” means a person specializes and is certified to provide external compression items, supplies and devices. A Certified Compression Therapist is trained in disease etiology of lymphatic and vascular disease, treatment available, all aspects of external compression specific to lymphatic and vascular disease, disease complications, contraindications of external compression modalities, effective disease management, conducting evaluations and need assessment, measurements, evaluating treatment progress, basic wound care, and basic knowledge of other treatment modalities available and related to lymphatic and vascular disease.

The nature of this law is to protect patient rights, assist patients with these diseases in obtaining proven effective treatment, avoiding inappropriate denials and delays in treatment by health insurers, improving the quality of health care, and improving the ability of the patient and physician to determine treatment course. These diseases are separate diseases of separate systems, while some are seen concurrent, they are treated in much the same way. These diseases are all chronic, and currently there is no cure. This law is designed to set a standard for effective disease treatment, management, thus reducing the cost of healthcare.

This law shall ensure coverage for early intervention, treatment, and management of lymphatic and vascular diseases. Health insurers shall cover and provide for their beneficiaries at least, but not limited to, the following:

Qualifying Factors:

Lymphedema: Any person who has been diagnosed upon a physical examination by their physician with lymphedema.

Chronic Venous Insufficiency: Any person who has been diagnosed upon a physical examination by their physician with chronic venous insufficiency.

Peripheral Vascular Disease: Any person who has been diagnosed upon a physical examination by their physician with peripheral vascular disease.

Therapy:

Physical Therapy for lymphatic and vascular disease, including MLD and CDT shall be considered medical services for disease management and prevention, and not physical or occupational therapy.

Certified Compression Therapists:

Shall be considered disease management specialists and not limited to durable medical equipment provisions to allow for reimbursement for evaluations, proper set-up and patient education, follow-up evaluations.

Lymphedema Management Program which shall consist of :

Early intervention shall include coverage for consult and education with a Certified Lymphedema therapist when the treating Oncologist has a reasonable expectation of cancer treatment consisting of lymph node removal and/or radiation for both males and females. The Certified Lymphedema therapist is to provide those anticipating being treated for cancer with lymph node removal and/or radiation with education and information on lymphedema, signs and symptoms to watch for, and treatments options. Management shall include a second consult and follow-up with a Certified Lymphedema therapist within three months of the cancer treatment, which included lymph node removal and/or radiation. This second consult shall include a review of information provided during the initial consultation.

Treatment shall include but are not limited to coverage for:

Mild to Moderate shall allow thirty physical therapy visits to include, but not limited to, treatment of MLD/CDT and application of external compression, patient education, and home management discharge planning.

Moderate to Severe shall allow for ninety visits of physical therapy visits to include, but not limited to initial evaluation, treatment of MLD and application of external compression, patient education, home management discharge planning. Coverage shall include treatment for all effected areas.

Follow-Up shall include but are not limited to coverage for:

Follow-up or management visits with a lymphedema specialist once every six months for the remainder of the patient’s lifetime. This visit is designed to assist the patient in continuing their home management program, adjusting it as needed, and keeping patients updated on new treatment options.

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External compression shall include but is not limited to coverage any item needed to achieve effective external compression as ordered by the treating physician. These items include, but are not limited to, graduated compression stockings, custom fabricated compression stockings, multilayered compression bandaging, external compression binders, and directional flow garments. Coverage for external compression pumps shall include gradient calibrated sequential compression pumps in which the garments consist of eight or more chambers, when ordered by the treating physician. Coverage shall include treatment for all affected areas of the body. Mechanical pumps which consist of calibrated gradient, sequential compression, with mechanical MLD mechanism shall be covered when ordered by the treating physician.

Podiatric Intervention and Footcare shall be covered monthly for toenail care for lymphedema patients when the lower extremity is affected.

Chronic Venous Insufficiency and Peripheral Vascular Disease Management Program which shall consist of but is not limited to:

Early Intervention shall include coverage for compression stockings, and custom fabricated compression stockings, physical therapy and other external compression items and devices as ordered by the treating physician when the patient has been diagnosed with chronic venous insufficiency or peripheral vascular disease.

External Compression shall include, but is not limited to coverage of compression stockings, custom fabricated compression stockings, external compression binders, Foam compression binders, Gradient Foam Compression Binders with pressure gauge, compression bandaging, multi layered compression bandaging, and directional flow garments. All external compression shall be covered for both standard and custom fit items and supplies. Calibrated gradient sequential compression pumps with the accompanying compression appliance consisting of eight or more chambers, for all affected areas of the body for purchase, shall be covered when ordered by the treating physician.

Podiatric Intervention and Footcare shall be covered monthly for toenail and wound prevention to include home podiatric care..

Wound Management shall include a requirement of a consultation or evaluation with a Certified Compression therapist, and the implementation of a disease management program. Patients experiencing wounds due to lymphatic and vascular disease, not including arterial disease, shall be placed on a home management program by a Certified Compression Therapist when wounds reoccur more than three times in one year, or wounds have been present for three months or longer.

Health Insurer’s Shall:

Provide policies, benefits, coverage guidelines, and provider contracting that will allow for coverage on all effective medical treatment and disease management for lymphatic and vascular disease.
Require providers to be certified lymphedema therapists or certified compression therapists.
Act in the best interest of providing a high quality of care and in the best interest of the beneficiary’s health care and quality of life.
Act in a fair, honest and ethical manner.

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Prohibited Actions of and Requirements of Insurers

Insurers shall approve treatment, and purchase of supplies and equipment needed to treat and manage vascular and lymphatic diseases as ordered by the treating physician, unless there is a clear indication that treatment would be contraindicated. Denials by insurers shall include a letter to the insured, the provider, and the ordering physician, and shall state a clear detailed reason for the denial, three or more clinical studies used in determining a reason for the denial, written guarantee that the patient will not suffer physical harm or exacerbation of their condition or further complication resulting from the denial, the credentials, training, and education specific to lymphatic and vascular disease of the person denying coverage, and shall be included with the letter of denial. Denials shall not be made due to a “lack of medical necessity”.
Insurer’s shall not engage in practicing medicine without a license or practicing medicine without physically examining a patient nor attempt to engage in such, by diagnosing or recommending treatment, by disputing the diagnosis of the examining and ordering physician, denying treatment exactly as ordered but agreeing to pay for a less expensive treatment, supply, or equipment.
Insurer’s may not obstruct a patients ability to receive effective treatment by requiring lease versus purchase of supplies and/or equipment when the treating physician’s order states a lifetime need, reducing allowed reimbursement below Medicare allowable, bundling fees, or imposing benefit limits of $350,000.00 or less per year per person, in addition to hospitalization benefits, on medical services, therapy or supplies and equipment deductibles exceeding $500.00 per year per person and less than 80% coverage for any treatment as ordered by the treating physician for lymphatic and vascular disease.
Insurers may not engage in down coding, or bundling reimbursement for treatment, supplies, or equipment ordered and billed as treatment for vascular and lymphatic disease.
Insurer’s may not engage in obstructing a patient’s ability to obtain effective treatment as ordered by the treating physician, in way.
Insurers may not delay treatment by requiring patient’s to obtain further testing, consult other physician’s and/or specialists, or requiring or recommending the trial of a less expensive treatment, supplies, or equipment.
Insurer’s may not exceed three business days in the approval of treatment, supplies, or equipment required for treatment, make every effort to act in the best interest of patient care, document such actions taken to act in the best interest of patient care, and provide such documentation to the patient, provider, and ordering physician within five business days upon their verbal or written request. Failure to comply with prior authorization deadline of three business days will result in the forfeiture of deductible and co-payment, or a penalty of $100.00 if coverage is 100% for each day exceeding the five day requirement of submission of documented actions taken to act in the best interest of patient care, and shall be paid to the beneficiary.
Insurers must require a physician’s prescription, a letter of medical necessity, but may not require copies of patients confidential medical records, history and physical, or any medical records that may violate a patient’s right to privacy in order to approve coverage. Insurers must require the physician’s letter of medical necessity to include diagnosis, and a treatment plan specific to each patient’s needs, lifestyle, and ability to apply treatment as ordered, and shall include risks if disease is not treated effectively, and prognosis with effective treatment.
Insurers may not deny coverage due to an assumption that the patient “may not be compliant”, or require a “equipment trial period to prove efficacy or to determine compliance”.
Insurers may not exceed twenty-five days upon receipt of a clean claim, or otherwise pay the claim at the full amount billed plus one-half times the amount billed for every thirty days the claim is overdue to be included in the payment of the claim to the provider, not through a separate process and department.

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe:

AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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For information about Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3

For information about How to Treat a Lymphedema Wound

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound

For information about Lymphedema Treatment

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment

For information about Exercises for Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema

For information on Infections Associated with Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema

For information on Lymphedema in Children

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

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Lymphedema People - Support Groups

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

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Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

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Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

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Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet? Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more. Come and take a stroll!

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema

Arm Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema

Leg Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema

Acute Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema

The Lymphedema Diet

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet