Florida Medicare decides to add lymphedema payments

Decision sets new precedent

Florida’s Medicare system recently delivered some good news to patients who suffer from lymphedema, the often-ignored and undertreated condition which manifests as sometimes severe limb swelling. The action makes Florida the first state in the nation to offer any type of treatment benefits to older patients afflicted with the condition. 

Lymphedema, an unfamiliar condition for many clinicians, is closely linked to chronic wounds, says John M. Macdonald, MD, a cardiovascular surgeon and director of the Wound Healing and Lymphedema Center in Ft. Lauderdale, FL. 

"A swollen lymph system is a prime site for infection, ulceration, and nonhealing wounds," explains Macdonald. About 50% of his clinic patients have some form of lymphedema that contributes to the nonhealing of their wounds, whether it’s a coronary bypass patient with lymphedema in the legs after vein harvesting, or a patient with cellulitis who is immobile and has swollen legs. In many cases, wound care and lymphedema care cannot be separated, he emphasizes. (See Wound Care, September 1997, pp. 101-103.) 

Sources say Florida Medicare’s decision to reimburse for lymphedema treatment is precedent-setting. No other Medicare system and very few private insurers offer any reimbursement for lymphedema treatment. Administrators who made the decision were reportedly impressed by testimony of patients and doctors familiar with the low-tech yet highly effective treatment methods for lymphedema, which most insurers in the United States disdainfully pigeonhole as "alternative medicine." 

Treatment often involves a regime called complex decongestive therapy (CDT), a combination of several therapeutic components such as massage, compression garments, remedial exercise, and dietary changes. CDT has been used widely and successfully in Europe since the 1930s, and is recognized as mainstream medicine there. 

But Florida Medicare’s decision, while viewed by many as a positive step in the recognition and treatment of lymphedema in the United States, has raised the ire of some. The new regulations put a two-week, 10-treatment cap on coverage, though they don’t place a specific dollar limit on treatment, which averages from $1,000 to $1,500 in cost. European regimes typically last a month, followed by patient self-care, says Macdonald. Critics say two weeks is insufficient for older patients suffering from more advanced stages of the disease, and have called the decision short-sighted. They fear that the Florida policy will serve as a national model for other state Medicare programs, and eventually for private insurers. 

Macdonald, who helped sway Florida Medicare toward coverage, contends that the fact that someone is finally going to pay for treatment should be viewed as a victory. "The two-week period means that we have to get patients to take care of themselves quickly," he says. "In Europe, the time is much longer, but their approach doesn’t fit the American lifestyle. At least we got the glass half-full. This will be a major part of wound care development in the future. I predict we’ll begin to see wound care and lymphedema centers popping up all over the country." 

Officials with Florida Medicare, which is administered by Blue Cross & Blue Shield of Florida, say they could review the lymphedema coverage. According to Sid Sewell, MD, medical director of Florida Medicare, the policy isn’t "written in stone" and time is needed before its effects can be gauged.

Treatable, not curable

Lymphedema is a chronic, incurable condition that appears as swelling in the arms and/or legs, and occasionally in other parts of the body. The condition can debilitate the afflicted. It is caused by the accumulation of lymphatic fluid in the interstitial tissue. Primary lymphedema can develop when lymphatic vessels are missing or impaired. Secondary lymphedema, which is more common, occurs when lymph vessels are damaged or removed during surgical procedures. 

Lymph nodes and vessels often are removed during operations to eradicate various types of cancer. Skin damage after radiation therapy also can lead to lymphedema. By some estimates, 25% to 30% of women who undergo breast cancer surgery experience some degree of arm swelling. CDT, followed by ongoing self-care or home care, often relieves symptoms considerably, allowing patients to lead a normal life. 

Lymphedema provides a ripe environment for the development of skin breakdown, infection, and inflammation. In addition, patients with severe leg lymphedema are apt to be immobile for long periods of time, thus heightening the risk for development of pressure sores. For a patient with one or more chronic wounds, lymphedema significantly decreases the level of oxygen perfusion to tissue and may severely delay or even prevent the healing process. 

"If you don’t eliminate lymphedema, you’ll have a difficult time healing a wound," Macdonald explains. "It seems that very few people have woken up to the fact that edema can be just as bad as insufficient blood supply in lowering the oxygen tension in the area of a wound. You have simply got to address the edema in order to heal the wound."