Lymphedema People Logo



STATE LEGISLATIVE PACKET (6) BOB WEISS

=========================

PROPOSED STATE LAW FOR THE TREATMENT OF LYMPHEDEMA
FOR STATE LEGISLATORS


This is a proposal to present a new law to treat lymphedema from all causes, primary as well as secondary, as a means of REDUCING medical costs to citizens and providers as well as the State Government. Similar legislation has been presented by Senator Susan Fargo in Massachusetts and Delegate Leo Wardrup in Virginia. The Virginia Bill passed both houses of the Virginia Assembly without dissenting vote, and was deemed to have no fiscal or budgetary impact by the Virginia Department of Corporations.

Elements of this new legislation should include:

1. DIAGNOSIS AND TREATMENT MANDATE– A mandate that all health insurance providers cover the costs of diagnosis and treatments for lymphedema;
2. MEDICAL MANAGEMENT– The course of therapy should be determined by a competent qualified physician knowledgeable of the diagnosis and current treatment of lymphedema;
3. MANUAL LYMPH DRAINAGE– Defined treatment should include a complete course of manual lymph drainage as part of complete decongestive therapy (Phase 1) when medically required, performed by physical therapists, occupational therapists, massage therapists or nurses who have taken specialized training in the treatment of lymphedema from a recognized training program and are licensed or certified by the appropriate governing board to perform treatments for lymphedema;
4. EXTENT OF TREATMENT– The schedule and number of manual lymph drainage treatment sessions is to be determined by the treating physician or therapist as required by medical necessity, and not the guidelines governing rehabilitation therapy;
5. PATIENT EDUCATION– Initial course of treatment (Phase 1) is to include training the patient to perform self-treatment in a home setting (Phase 2), including self-manual lymph drainage, bandaging, wearing and care of compression garments, use of specialized manually adjustable compression devices, donning aids, and other required ancillary equipment and techniques for self-measurement. Patient training is also to include information on skin care, the risk of infection and the steps to be taken if infection occurs and exercises;
6. COMPRESSION BANDAGES AND GARMENTS– Coverage is to be provided for any compression garments, bandages and devices deemed by the patient’s qualified caregiver to be medically necessary, with replacements provided when required to maintain the compressive function or to accommodate changes in the patient’s dimensions;
7. FOLLOW-UP TREATMENT– Coverage is to be provided for follow-up treatments when medically required, or periodically to validate and update patient’s home treatment techniques, to monitor progress against the written treatment plan and to modify the treatment plan as required;
8. DENIAL OF TREATMENT– No individual, other than a licensed physician and surgeon competent to evaluate the specific clinical issues involved in the care requested, may deny requests for authorization of health care services pursuant to this section.
9. MEASUREMENT TO DEFINE TREATMENT EFFICACY– Periodic measurements of lymph volume and patient weight should be made to insure the effectiveness of the treatment plan and patient compliance, to enable modification of the treatment plan and to determine the need for follow-up courses of treatment.
10. PROHIBITION OF ADDITIONAL TREATMENT FEES– No additional fees or deductibles to be assessed for compliance with this statute other than already exists in the coverage contract for medical services.
11. NOT A NEW HEALTH CARE MANDATE- This law does not create a new health care mandate. It assures that lymphedema patients are properly diagnosed and treated utilizing existing medical staff, facilities and materials under the existing contract provisions for co-payments and deductibles.

There is an important fiscal aspect to this problem:

Millions of dollars are being spent unnecessarily by medical providers to treat cellulitis and lymphangitis resulting indirectly from denials by Medicare of the preventive treatment modalities accepted by NIH NCI, ACS, ISL, NLN, LRF and most other knowledgeable medical and therapeutic organizations;
Millions of dollars are being spent unnecessarily in needless appeals of Medicare denials around the country--many of which are being reversed by Administrative Law Judges who recognize that the current standard of lymphedema care includes CDT.
Millions of dollars are being wasted because the expensive Medicare-approved pneumatic pumps are ending up unused by patients who find that they don't help or have caused further bodily damage--and these same patients are discouraged from seeking the treatment most likely to help them because there is no coverage of this treatment.
Millions of dollars are being wasted in administering pharmaceuticals to manage the pain caused by the swelling of untreated or undertreated lymphedema.
Millions of dollars are being wasted to compensate for the disability caused by inability to walk or drive or to do useful work with the arms and hands because of the swelling of untreated lymphedema.

Lymphedema treatment is a “win/win” situation. It is good medicine and good business. The time has come to fight this "hidden epidemic" lymphedema.

Please feel free to contact us for any help you may need. We can provide a Lymphedema Treatment Fact Sheet, Impact Analysis (Medical, Social, Fiscal), Cost-Efficacy Analysis, Substantiation of Provisions, Statistical Surveys, Texts of the Virginia and Massachusetts bills, etc. upon request.


Robert and Pearl Weiss
10671 Baton Rouge Avenue
Northridge, CA 91326
Tel: 818-368-6340
Fax: 818-368-6432
E-mail: LymphActivist@aol.com

.......................

BILL NUMBER:

INTRODUCED BY:

An act to add Section 1367.XX to the Health and Safety Code, and to add Section 10123.XX to the Insurance Code, relating to health coverage.

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1. This act shall be known and may be cited as the Lymphedema Treatment Act of 2004.

SEC. 2. Section 1367.XX is added to the Health and Safety Code, to read:

1367.XX. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or after January 1, 2005, that covers hospital, medical or surgery expenses, shall include coverage for the medical diagnosis and treatment of lymphedema in accordance with the current standard of care of lymphedema, and shall do all of the following:

(1) Cover the costs of differential diagnoses of lymphedema from all causes by a qualified physician knowledgeable of the diagnosis and current treatment standards of lymphedema, including primary lymphedema and secondary lymphedema resulting from surgical or radiation treatments of cancer as well as from surgical procedures and other origins (e.g. injuries, burns, inflammation), and the treatment of lymphedema by a qualified lymphedema therapist according to current standard of lymphedema care. This section applies, but is not limited, to the diagnosis and treatment of lymphedema of the upper and lower limbs, face and neck, upper and lower torso and genitalia.

(2) The course of therapy should be determined by a qualified, competent physician or therapist knowledgeable of the diagnosis and current treatment standards of lymphedema (as defined by the National Lymphedema Network, International Lymphology Society, American Cancer Society, National Cancer Institute or the American Medical Association). Treatment provided should include a course of manual lymph drainage (MLD) whose length, duration and frequency are determined on the basis of medical necessity, and not guidelines governing rehabilitative therapy. A treatment plan shall be written defining the goal of the therapy, the schedule and the measurements to be made to validate the efficacy of the treatment and patient compliance;

(3) The MLD shall be performed by therapists who: have taken specialized training in the treatment of lymphedema from a recognized training program; are certified by the Lymphology Association of North America (LANA) or by other schools to equivalent levels (a minimum of 135 hours dedicated to lymphedema treatment); and are licensed or registered by the appropriate governing board to perform treatments for lymphedema. If a provider delegates outpatient treatment to contracting providers, the plan shall require contracting providers to ensure that lymphedema outpatient treatment is provided by appropriately licensed or registered health care professionals who are trained and certified in the specifics of lymphedema therapy to the same levels as that required for the plan.

(4) The initial course of treatment (Phase 1) is to include training of the patient to perform self-treatment in a home setting (Phase 2), including, as appropriate, bandaging, wearing and care of compression garments, use of specialized manually adjustable compression devices, donning aids, and other required ancillary equipment, and techniques for self-measurement. Patient training is also to include information on skin care, prophylactic measures to reduce the risk of infection, recognition of early infection and the steps to be taken if infection occurs. The goal of these instructions is to enable lymphedema patients and their families to gain an understanding of the lymphatic disease process and its daily management by complex decongestive therapy, and thereby to avoid frequent hospitalizations and complications.

If a plan delegates outpatient self-management training to contracting providers, the plan shall require contracting providers to ensure that lymphedema outpatient self-management training and education are provided by appropriately licensed or registered health care professionals who are trained and certified in the specifics of lymphedema therapy.

(5) Coverage is to be provided for all medically-required compression garments, bandage systems and devices deemed by the patient’s qualified caregiver to be medically necessary, with replacements provided when required to maintain the compressive function or to accommodate changes in the patient’s dimensions, even if the items are available without a prescription. Fitting and adjustment of compression garments and devices is to be performed by fitters who are certified by the garment or device manufacturer.

(6) Coverage is to be provided for follow-up treatments when medically required, or periodically to validate and update patient’s home treatment techniques, to monitor progress against the written treatment plan and to modify the treatment plan as required;

(7) Periodic measurements of edema volume and patient body weight shall be made to insure the effectiveness of the treatment plan and patient compliance, to enable modification of the treatment plan and to determine the need for follow-up courses of treatment.

(b) As used in this section, current treatment standards of lymphedema refers to the accepted medical standards for the diagnosis and treatment of lymphedema as defined by knowledgeable medical specialty groups such as the National Lymphedema Network Medical Advisory Committee, International Lymphology Society, American Cancer Society, National Cancer Institute or the American Medical Association. The following definitions (adapted from the ACS Lymphedema Workshop consensus recommendation in Cancer Supplement, 1998; 83:2882-5) apply:
(1) Complex Decongestive Therapy (CDT) comprises a number of interrelated treatment modalities that are most efficacious when utilized in an interdependent fashion:
(A) Proper skin care will optimize the supple texture of the skin and, with the other components of this therapy, minimize the risk of infection through cutaneous portals of entry;
(B) Manual lymph drainage (MLD) is a specialized form of massage that has been demonstrated to stimulate and direct lymphatic flow, thereby decreasing the edema and fibrous changes of the involved extremity;
(C) Compression therapy includes application of multilayered low-stretch bandages (with appropriate padding) to enhance the effect of muscular activity upon the clearance of lymphatic fluid from the affected body part. Non-elastic manually-adjustable compression devices may be worn during non-active periods and elastic compression garments may be worn during active portions of the day;
(D) Exercise can include, but may not be limited to, active range of motion, and should be individuated according to the patient's medical and psychosocial needs and capacity. Exercise is maximally effective when performed while the lymphedematous limb is bandaged.

(c) No individual, other than a licensed physician and surgeon competent to evaluate the specific clinical issues involved in the care requested, may deny requests for authorization of health care services and materials pursuant to this section.

(d) Patients undergoing any surgery or radiotherapy procedure shall be given information on the risk of lymphedema associated with that procedure, and the potential post-procedure symptoms of lymphedema. Informed consent agreements for all surgeries and radiation therapies shall include information on the risk of lymphedema associated with the alternative procedures.

(e) The co-payments and deductibles for the benefits specified in subdivision (a) shall not exceed those established for similar benefits within the given plan.

(f) No health care service plan shall do any of the following in providing the coverage described in subdivision (a):
(1) Reduce or limit the reimbursement of the attending provider for providing care to an individual enrollee or subscriber in accordance with the coverage requirements.
(2) Provide monetary or other incentives to an attending provider to induce the provider to provide care to an individual enrollee or subscriber in a manner inconsistent with the coverage requirements.
(3) Provide monetary payments or rebates to an individual enrollee or subscriber to encourage acceptance of less than the coverage requirements.
(4)Reduce or eliminate coverage as a result of the requirements of this section.

(g) On or after July 1, 2005, every health care service plan governed by this section shall include notice of the coverage required by this section in the plan's evidence of coverage and disclosure forms.

(h) Nothing in this section shall be construed to limit retrospective utilization review and quality assurance activities by the plan.

(i) Nothing in this section shall be construed to establish a new mandated benefit or to prevent application of deductible or co-payment provisions in a policy or plan, nor shall this section be construed to require that a policy or plan be extended to cover any other procedures under an individual or a group health care service plan contract. Nothing in this section shall be construed to authorize an enrollee to receive the services required to be covered by this section if those services are furnished by a non-participating provider, unless the enrollee is referred to that provider by a participating physician or nurse practitioner providing care.

SEC. 3. Section 10123.XX is added to the Insurance Code, to read:

10123.XX. (a) Every policy of disability insurance covering hospital, surgical, or medical expenses that is issued, amended, renewed, or delivered on or after January 1, 2005, that covers hospital, medical or surgery expenses, shall include coverage for the medical diagnosis and treatment of lymphedema in accordance with the current standard of care as determined by the National Lymphedema Network Medical Advisory Committee, and shall do all of the following:

(1) Cover the costs of differential diagnoses and treatments for lymphedema from all causes, including primary lymphedema and secondary lymphedema resulting from surgical or radiation treatments of cancer as well as from surgical procedures and other origins (e.g. injuries, burns, inflammation). This section applies, but is not limited, to the diagnosis and treatment of lymphedema of the upper and lower limbs, face and neck, upper and lower torso and genitalia.

(2) The course of therapy should be determined by a qualified, competent physician or therapist knowledgeable of the diagnosis and current treatment standards of lymphedema (as defined by the National Lymphedema Network, International Lymphology Society, American Cancer Society, National Cancer Institute and the American Medical Association). Treatment provided should include a course of manual lymph drainage (MLD) whose length, duration and frequency are determined on the basis of medical necessity, and not guidelines governing rehabilitative therapy. A treatment plan shall be written defining the goal of the therapy, the schedule and the measurements to be made to validate the efficacy of the treatment and patient compliance;

(3) The MLD shall be performed by physical therapists, occupational therapists, massage therapists or nurses, who are certified by the Lymphology Association of North America (LANA) or by other schools to equivalent levels (a minimum of 130 hours dedicated to lymphedema treatment), and licensed or registered by the appropriate governing board to perform treatments for lymphedema. If a provider delegates outpatient treatment to contracting providers, the plan shall require contracting providers to ensure that lymphedema outpatient treatment is provided by appropriately licensed or registered health care professionals who are trained and certified in the specifics of lymphedema therapy to the same levels as that required for the provider.

(4) The initial course of treatment (Phase 1) is to include training of the patient to perform self-treatment in a home setting (Phase 2), including self-manual lymph drainage, bandaging, wearing and care of compression garments, use of specialized manually adjustable compression devices, donning aids, and other required ancillary equipment, and techniques for self-measurement. Patient training is also to include information on skin care, prophylactic measures to reduce the risk of infection, recognition of early infection and the steps to be taken if infection occurs. These benefits shall include, but not be limited to, instruction that will enable lymphedema patients and their families to gain an understanding of the lymphatic disease process and its daily management by means of complex decongestive therapy, in order to thereby avoid frequent hospitalizations and complications.

If a provider delegates outpatient self-management training to contracting providers, the plan shall require contracting providers to ensure that lymphedema outpatient self-management training and education are provided by appropriately licensed or registered health care professionals who are trained and certified in the specifics of lymphedema therapy.

(5) Coverage is to be provided for all medically-required compression garments, bandage systems and devices deemed by the patient’s qualified caregiver to be medically necessary, with replacements provided when required to maintain the compressive function or to accommodate changes in the patient’s dimensions, even if the items are available without a prescription. Fitting and adjustment of compression garments and devices is to be performed by fitters who are certified by the garment or device manufacturer.

(6) Coverage is to be provided for follow-up treatments when medically required, or periodically to validate and update patient’s home treatment techniques, to monitor progress against the written treatment plan and to modify the treatment plan as required;

(7) Periodic measurements of edema volume and patient body weight shall be made to insure the effectiveness of the treatment plan and patient compliance, to enable modification of the treatment plan and to determine the need for follow-up courses of treatment.

(b) As used in this section, all of the following definitions (adapted from the ACS Lymphedema Workshop consensus recommendation in Cancer Supplement, 1998; 83:2882-5) apply:
(1) Complex Decongestive Therapy (CDT) comprises a number of interrelated treatment modalities that are most efficacious when utilized in an interdependent fashion:
(A) Proper skin care will optimize the supple texture of the skin and, with the other components of this therapy, minimize the risk of infection through cutaneous portals of entry;
(B) Manual lymph drainage (MLD) is a specialized form of massage that has been demonstrated to stimulate and direct lymphatic flow, thereby decreasing the edema and fibrous changes of the involved extremity;
(C) Compression therapy includes application of multilayered low-stretch bandages (with appropriate padding) to enhance the effect of muscular activity upon the clearance of lymphatic fluid from the affected body part. Non-elastic manually-adjustable compression devices may be worn during non-active periods and elastic compression garments may be worn during active portions of the day;
(D) Exercise can include, but may not be limited to, active range of motion, and should be individuated according to the patient's medical and psychosocial needs and capacity. Exercise is maximally effective when performed while the lymphedematous limb is bandaged.

(c) No individual, other than a licensed physician and surgeon competent to evaluate the specific clinical issues involved in the care requested, may deny requests for authorization of health care services and materials pursuant to this section.

(d) Patients undergoing any surgery or radiotherapy procedure shall be given information on the risk of lymphedema associated with that procedure, and the potential post-procedure symptoms of lymphedema. Informed consent agreements for all surgeries and radiation therapies shall include information on the risk of lymphedema associated with the alternative procedures.

(e) The co-payments and deductibles for the benefits specified in subdivision (a) shall not exceed those established for similar benefits within the given insurance policy.

(f) No insurer shall do any of the following in providing the coverage described in subdivision (a):
(1) Reduce or limit the reimbursement of the attending provider for providing care to an insured in accordance with the coverage requirements.
(2) Provide monetary or other incentives to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with the coverage requirements.
(3) Provide monetary payments or rebates to an insured to encourage acceptance of less than the coverage requirements.
(4) Reduce or eliminate coverage as a result of the requirements of this section.

(g) On or after July 1, 2005, every insurer governed by this section shall include notice of the coverage required by this section in the insurer's evidence of
coverage or certificate of insurance.

(h) Nothing in this section shall be construed to limit retrospective utilization review and quality assurance activities by the insurer.

(i) Nothing in this section shall be construed to establish a new mandated benefit or to prevent application of deductible or co-payment provisions in a policy, nor shall this section be construed to require that a policy be extended to cover any other procedures under an individual or a group health care policy. Nothing in this section shall be construed to authorize an insured to receive the services required to be covered by this section if those services are furnished by a non-participating provider, unless the insured is referred to that provider by a participating physician or nurse practitioner providing care.

(j) This section shall only apply to health benefit plans, as defined in subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity insurance, coverage for benefits under this section shall apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy. Nothing in this section shall be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance.

================================================

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

================================================

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 

Exercises for Lymphedema  

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

Diuretics are not for Lymphedema 

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

Lymphedema People Online Support Groups 

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

Lipedema 

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

Treatment 

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

Lymphedema and Pain Management 

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

Manual Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)

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

Infections Associated with Lymphedema 

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

How to Treat a Lymphedema Wound 

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

Fungal Infections Associated with Lymphedema 

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

Lymphedema in Children 

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

Lymphoscintigraphy 

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

Magnetic Resonance Imaging 

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

Extraperitoneal para-aortic lymph node dissection (EPLND) 

http://www.lymphedemapeople.com/wiki/doku.php?id=extraperitoneal_para-aortic_lymph_node_dissection_eplnd 

Axillary node biopsy 

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

Sentinel Node Biopsy 

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

 Small Needle Biopsy - Fine Needle Aspiration 

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

Magnetic Resonance Imaging 

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

Lymphedema Gene FOXC2

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_foxc2

 Lymphedema Gene VEGFC

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

 Lymphedema Gene SOX18

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18

 Lymphedema and Pregnancy

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

Home page: Lymphedema People

http://www.lymphedemapeople.com

Page Updated: Dec. 17, 2011