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)
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)
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