CMS has added a new HCPCS Code to cover
a bilateral segmental pneumatic garment which treats the entire
lower body, including legs, hips and abdomen, to be
used with the Lympha Press Optimal® sequential compression
system.
E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK
Code is being reused with a new description after being terminated for five years. Please review the long description and dates of service carefully to ensure you are using the most appropriate code. This code will be available for submission starting 1/1/13. Consult PDAC for pricing.
Lymphovenous
Canada: How effective are pneumatic extremity pumps in treating
lymphedema?Although
extremity pumps have been used since the late
1960's, there has been some debate on their effectiveness.
Recent
studies suggest that pumps can play a useful role in treating lymphedema and
that claims pumps are
harmful are highly exaggerated. Below is
selected research which has been recently conducted in this
area.Cautions do exist on using pumps. They are not recommended during
episodes of inflammatory
phlebitis or pulmonary embolism (blood
clots). Some researchers (Boris, 1998)
1. have suggested that lower limb
users may be at risk of developing genital lymphedema while others
(Brennan, 1998)
2. have warned against using a pump during an
infection, metastatic disease and ongoing radiation. As with
any
treatment, patients should consult with their doctor and/or licensed and
reputable health care
professionals before embarking on any
treatment regime.Some clinicians in the area have suggested that
multi-chamber (segmented) pumps with calibrated pressure gradients are
more effective than single chamber
pumps without gradient pressure,
although an American evaluation undertaken in 1998 by the Blue Cross
Blue Shield Technology Evaluation Center (TEC) comparing the efficacy
of different types of pneumatic
extremity pumps found there was
& quot;insufficient evidence to permit conclusions regarding whether the
efficacy of lymphedema pumps varies across pump
type."
3.Most researchers recommend the use of compression
garments to maintain the reduction of edema after
pump use. Many
suggest conservative treatments such as elevation, exercise, massage and the
use of
compression garments prior to using extremity pumps.More
objective scientific research is clearly called for
to determine
under what conditions extremity pumps work most effectively on persons who have
lymphatic
conditions.
1. Boris M, Weindorf S, Lasinski BB.
The risk of genital edema after external pump compression for lower
limb lymphedema. Lymphology 1998 Mar;31(1):15-202. Brennan MJ.
Lymphedema Following the Surgical
Treatment of Breast Cancer:A
Review of Pathophysiology and Treatment, Journal of Pain and Symptom
Management
1992;7:110-116.3. Lefevre, F. Special Report: Comparative efficacy of different
types of
pneumatic compression pumps for the treatment of
lymphedema, Blue Cross Blue Shield Association,
1998.A
Retrospective Study of the Effects of the Lymphapress Pumpon Lymphedema in a
Pediatric
PopulationLymphology 34(2001) 156-165by A. Hassall, C.
Graveline and P. Hilliard,Dept. of
Rehabilitation Services, the
Hospital for Sick Children, Toronto, Ont.This study reports positive results
from
the use of the Lymphapress pump (LP, Global Medical Imports,
Digby, N.S., Canada) studied
retrospectively on 16 children with
primary or secondary lymphedema of the upper or lower extremities by
measuring
the volume and circumference of the limbs before and after treatment.The study
notes that
clinicians at the Hospital for Sick Children have used
the Lymphapress Pump (LP) with no noticeable side
effects. They
state in the study that although advocates of manual lymph drainage maintain
that use of the LP
leads to the development of fibrous bands which
further impede lymph drainage or produce lymphedema in
unaffected
limbs, the effectiveness of physiotherapy in the management of lymphedema has
not be
documented. "No randomized controlled trials in
adults or children have been reported. No study of
these two
therapies has produced statistically significant findings in favour of one over
the other."The
study reported that 88% of their subjects
experienced no complications directly arising from pump use. The
more serious complications of lymphedema, genital and truncal edemas
did not appear to be caused by the
pump nor did it cause lymphedema
in the unaffected limb."The boy with bilaterial LE lymphedema and
edema of the groin and scrotum was reluctant to discontinue pumping
despite these regional swellings,
because he had a decrease in
infectious episodes while on treatment. It remains unclear whether pumping
when these comorbid conditions are present is harmful."They
conclude by suggesting that more
research is needed:at a
microcirculatory level on the effects of compression on lymphatic structure in
both
children and adults;the validity and reliability of the
thigh-to-foot ratio measures used to evaluate bilateral
lymphedema;whether the Lymphapress pump, complex physical therapy, or a
combination of the two is the
best non-operative method to control
childhood lymphedema.Some flaws with the study are noted in the
editorial "Pumps and Lymphedema" (pgs. 150-151) - such
as:the small sample,the variation of
protocol from 2-7 days per
week, andthe use of exercise and compression garments with the pumpEditor
Charles Witte writes, "overwhelming benefits and advantages of
complex physical therapy have been
claimed, and an aura of fear and
apprehension has evolved surrounding these dogmatic warnings to avoid
compression
devices." Witte adds that despite the high cost of the devices and
their dubious benefit,
"it is also apparent that these
devices have been used for a long time, that serious documented
complications of their appropriate use are infrequent, and even these
are largely related to transient edema
accumulation in the genital
region after application to the lower extremities."He concludes,
saying,
"Careful analysis of this paper suggests that
pneumatic compression has limited, if any, value in the
treatment
of lymphedema. On the other hand, one suspects that the complications and
dangers often
attributed to usage of 'pumps' are exaggerated and
overblown."
The authors can be contacted for more information
through:Ms. Alison Hassall, BSc. PTDept. of
Rehabilitation
ServicesThe Hospital for Sick Children555 University Ave.Toronto, Ont.Tel:
(416)
813-6755Fax: (416) 813-8557
A copy of the study can be
obtained from the Lymphology journal by writing: Charles L. Witte, M.D.,
Arizona Health Sciences Center, Dept. of Surgery (GS&T), P.O.
Box 245063, Tucson, AZ
85724-5063 USA Tel: (520) 626-6118 Fax:(520)
625-0822.
Clinical practice guidelines: pneumatic compression pumpsFrom:
Clinical practice guidelines for the care and
treatment of breast
cancer: 11. Lymphedema Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark
Levine, for the Steering Committee for Clinical Practice Guidelines
for the Care and Treatment of Breast
Cancer CMAJ
2001;164(2):191-9One randomized trial has demonstrated a trend in favour of
pneumatic
compression pumps compared with no treatment. Further
randomized trials are required to determine
whether pneumatic
compression provides additional benefit over compression garments alone. There
has
been only one randomized trial that has evaluated pneumatic
compression pumps for the treatment of
lymphedema.Dini and
colleagues35. assigned 80 women with postmastectomy lymphedema to either
intermittent pneumatic compression or no treatment. Women in the
treatment group underwent a 2-week
cycle of 5 pump sessions per
week, each session lasting 2 hours, followed by a 5-week break, and then
another 2-week treatment cycle. Although the mean decrease in arm
circumference in the treatment group
was nearly 4 times that in the
control group (1.9 cm v. 0.5 cm), the post-test differences between the 2
groups failed to reach statistical significance (p = 0.084), possibly
because of the small sample and the large
variability in both the
initial arm measurements and the circumferential changes within each group
(level II
evidence).The experience with lymphedema pumps has also
been reported in a number of level V
studies.36,37,38,39,40,41,42
The results have been mixed. These studies were limited by their small
samples, mixed populations (arm and leg edema), lack of control groups
and lack of outcome measures that
assessed symptoms such as pain
and heaviness. In one study pneumatic compression produced a reduction
in lymphedema volume that was 18% greater than the reduction produced
by elastic compression;41. in
another study no difference was
detected between elastic compression and pneumatic compression.36.No
comparative
studies have been published to determine the most effective pumping time,
pressure levels or
kind of pump. There is a suggestion,44. but not
unanimous agreement,43. that sequential, multichambered
pumps are
more effective than monochambered pumps. The former produce a linear pressure
wave from
distal to proximal portions of the limb that reduces the
tendency of fluid to collect in the hand. There are
several
commercially available pumps, ranging in complexity and cost. Most pumps used
by therapists,
clinics and consumers are complex and cost several
thousand dollars. Pump therapy is contraindicated in the
presence
of active infection or deep vein thrombosis in the limb.35. Dini D, Del Mastro
L, Gozz A, Lionetto
R, Garrone O, Forno G, et al. The role of
pneumatic compression in the treatment of postmastectomy
lymphedema. A randomized phase III study. Ann Oncol 1998;9:187-91.36.
Bertelli G, Venturini M, Forno
G, Macchiavello F, Dini D. An
analysis of prognostic factors in response to conservative treatment of
postmastectomy lymphedema. Surg Gynecol Obstet 1992;175:455-60.37.
Kim-Sing C, Basco VE.
Postmastectomy lymphedema treated with the
Wright linear pump. Can J Surg 1987;30:368-70.38. Pappas
CJ,
O'Donnell TF. Long-term results of compression treatment for lymphedema. J Vasc
Surg
1992;16:555-62.39. Klein MJ, Alexander MA, Wright JM, Redmond
CK, LeGasse AA. Treatment of
adult lower extremity lymphedema with
the Wright linear pump: statistical analysis of a clinical trial. Arch
Phys Med Rehabil 1988;69:202-6.40. Raines JK, O'Donnell TF, Kalisher L,
Darling RC. Selection of
patients with lymphedema for compression
therapy. Am J Surg 1977;133:430-7.41. Swedborg I. Effects of
treatment with an elastic sleeve and intermittent pneumatic compression
in post-mastectomy patients with
lymphedema of the arm. Scand J
Rehabil Med 1984;16:35-41.42. Richmand DM, O'Donnell TF Jr,
Zelikovski A. Sequential pneumatic compression for lymphedema. Arch
Surg 1985;120:1116-9.
Medical supply stores can order pumps for you. Two
places I have heard of that works with insurance plans
is:http://advancedrehabtechnologies.net/
and
http://www.absolutemedical.net/
With all the different insurance
plans out there, getting reimbursed is complicated. Many standard Medical
Equipment companies may not have the knowledge to get the
multi-chambered, gradient pumps covered.
And they are
expensive.Medicare does require that conservative methods be tried for at least
thirty days
before the best equipment. And there are different
requirements for different types of Lymphedema. Cancer
patients
have different standards than do patients w/ venous ulcer problems. At my
company, Advanced
Rehab Technologies, Inc. we often put a standard,
non gradient pump on a patient for a month trial, so as to
meet
Medicare expectations. If the patient fails, or has problems with this pump,
then we can move forward
with the more advanced pump.
Soundsbackwards , but that is the insurance issue today.As always, pumps
are not the total solution. Follow your medical professionals advice
and follow a multi-faceted approach to
dealing with it.Sincerely,
Dan Dulnikowski of Advanced Rehab Technology**Dan is a valued member of
Lymphland International Lymphedema Support Online.
Absolute
Medical, Inc. is a durable medical equipment company that is committed to
providing the best in
home compression pump therapy for people with
chronic edemas including primary and secondary
lymphedema, chronic
venous insufficiency, long-standing (venous return) ulcers, and other vascular
disorders.We also offer...Insurance coverage verification for all
varieties of insurance including
Medicare.Direct insurance billing
for qualifying patients.At-home equipment installation and
set-up.Comprehensive instruction by qualified personnel.And 24-hour
customer service.
Influence of Age and Gender on Human Lymphatic Pumping Pressure in the
Leg. This Japanese study published in Lymphology 44 (2011) 113-120
found that the age-related decrease in lymphatic pumping pressure was more
marked in females of postmenopausal age.
E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK
Code is being reused with a new description after being terminated for five years. Please review the long description and dates of service carefully to ensure you are using the most appropriate code. This code will be available for submission starting 1/1/13. Consult PDAC for pricing.
Lymphovenous
Canada: How effective are pneumatic extremity pumps in treating
lymphedema?Although
extremity pumps have been used since the late
1960's, there has been some debate on their effectiveness.
Recent
studies suggest that pumps can play a useful role in treating lymphedema and
that claims pumps are
harmful are highly exaggerated. Below is
selected research which has been recently conducted in this
area.Cautions do exist on using pumps. They are not recommended during
episodes of inflammatory
phlebitis or pulmonary embolism (blood
clots). Some researchers (Boris, 1998)
1. have suggested that lower limb
users may be at risk of developing genital lymphedema while others
(Brennan, 1998)
2. have warned against using a pump during an
infection, metastatic disease and ongoing radiation. As with
any
treatment, patients should consult with their doctor and/or licensed and
reputable health care
professionals before embarking on any
treatment regime.Some clinicians in the area have suggested that
multi-chamber (segmented) pumps with calibrated pressure gradients are
more effective than single chamber
pumps without gradient pressure,
although an American evaluation undertaken in 1998 by the Blue Cross
Blue Shield Technology Evaluation Center (TEC) comparing the efficacy
of different types of pneumatic
extremity pumps found there was
& quot;insufficient evidence to permit conclusions regarding whether the
efficacy of lymphedema pumps varies across pump
type."
3.Most researchers recommend the use of compression
garments to maintain the reduction of edema after
pump use. Many
suggest conservative treatments such as elevation, exercise, massage and the
use of
compression garments prior to using extremity pumps.More
objective scientific research is clearly called for
to determine
under what conditions extremity pumps work most effectively on persons who have
lymphatic
conditions.
1. Boris M, Weindorf S, Lasinski BB.
The risk of genital edema after external pump compression for lower
limb lymphedema. Lymphology 1998 Mar;31(1):15-202. Brennan MJ.
Lymphedema Following the Surgical
Treatment of Breast Cancer:A
Review of Pathophysiology and Treatment, Journal of Pain and Symptom
Management
1992;7:110-116.3. Lefevre, F. Special Report: Comparative efficacy of different
types of
pneumatic compression pumps for the treatment of
lymphedema, Blue Cross Blue Shield Association,
1998.A
Retrospective Study of the Effects of the Lymphapress Pumpon Lymphedema in a
Pediatric
PopulationLymphology 34(2001) 156-165by A. Hassall, C.
Graveline and P. Hilliard,Dept. of
Rehabilitation Services, the
Hospital for Sick Children, Toronto, Ont.This study reports positive results
from
the use of the Lymphapress pump (LP, Global Medical Imports,
Digby, N.S., Canada) studied
retrospectively on 16 children with
primary or secondary lymphedema of the upper or lower extremities by
measuring
the volume and circumference of the limbs before and after treatment.The study
notes that
clinicians at the Hospital for Sick Children have used
the Lymphapress Pump (LP) with no noticeable side
effects. They
state in the study that although advocates of manual lymph drainage maintain
that use of the LP
leads to the development of fibrous bands which
further impede lymph drainage or produce lymphedema in
unaffected
limbs, the effectiveness of physiotherapy in the management of lymphedema has
not be
documented. "No randomized controlled trials in
adults or children have been reported. No study of
these two
therapies has produced statistically significant findings in favour of one over
the other."The
study reported that 88% of their subjects
experienced no complications directly arising from pump use. The
more serious complications of lymphedema, genital and truncal edemas
did not appear to be caused by the
pump nor did it cause lymphedema
in the unaffected limb."The boy with bilaterial LE lymphedema and
edema of the groin and scrotum was reluctant to discontinue pumping
despite these regional swellings,
because he had a decrease in
infectious episodes while on treatment. It remains unclear whether pumping
when these comorbid conditions are present is harmful."They
conclude by suggesting that more
research is needed:at a
microcirculatory level on the effects of compression on lymphatic structure in
both
children and adults;the validity and reliability of the
thigh-to-foot ratio measures used to evaluate bilateral
lymphedema;whether the Lymphapress pump, complex physical therapy, or a
combination of the two is the
best non-operative method to control
childhood lymphedema.Some flaws with the study are noted in the
editorial "Pumps and Lymphedema" (pgs. 150-151) - such
as:the small sample,the variation of
protocol from 2-7 days per
week, andthe use of exercise and compression garments with the pumpEditor
Charles Witte writes, "overwhelming benefits and advantages of
complex physical therapy have been
claimed, and an aura of fear and
apprehension has evolved surrounding these dogmatic warnings to avoid
compression
devices." Witte adds that despite the high cost of the devices and
their dubious benefit,
"it is also apparent that these
devices have been used for a long time, that serious documented
complications of their appropriate use are infrequent, and even these
are largely related to transient edema
accumulation in the genital
region after application to the lower extremities."He concludes,
saying,
"Careful analysis of this paper suggests that
pneumatic compression has limited, if any, value in the
treatment
of lymphedema. On the other hand, one suspects that the complications and
dangers often
attributed to usage of 'pumps' are exaggerated and
overblown."
The authors can be contacted for more information
through:Ms. Alison Hassall, BSc. PTDept. of
Rehabilitation
ServicesThe Hospital for Sick Children555 University Ave.Toronto, Ont.Tel:
(416)
813-6755Fax: (416) 813-8557
A copy of the study can be
obtained from the Lymphology journal by writing: Charles L. Witte, M.D.,
Arizona Health Sciences Center, Dept. of Surgery (GS&T), P.O.
Box 245063, Tucson, AZ
85724-5063 USA Tel: (520) 626-6118 Fax:(520)
625-0822.
Clinical practice guidelines: pneumatic compression pumpsFrom:
Clinical practice guidelines for the care and
treatment of breast
cancer: 11. Lymphedema Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark
Levine, for the Steering Committee for Clinical Practice Guidelines
for the Care and Treatment of Breast
Cancer CMAJ
2001;164(2):191-9One randomized trial has demonstrated a trend in favour of
pneumatic
compression pumps compared with no treatment. Further
randomized trials are required to determine
whether pneumatic
compression provides additional benefit over compression garments alone. There
has
been only one randomized trial that has evaluated pneumatic
compression pumps for the treatment of
lymphedema.Dini and
colleagues35. assigned 80 women with postmastectomy lymphedema to either
intermittent pneumatic compression or no treatment. Women in the
treatment group underwent a 2-week
cycle of 5 pump sessions per
week, each session lasting 2 hours, followed by a 5-week break, and then
another 2-week treatment cycle. Although the mean decrease in arm
circumference in the treatment group
was nearly 4 times that in the
control group (1.9 cm v. 0.5 cm), the post-test differences between the 2
groups failed to reach statistical significance (p = 0.084), possibly
because of the small sample and the large
variability in both the
initial arm measurements and the circumferential changes within each group
(level II
evidence).The experience with lymphedema pumps has also
been reported in a number of level V
studies.36,37,38,39,40,41,42
The results have been mixed. These studies were limited by their small
samples, mixed populations (arm and leg edema), lack of control groups
and lack of outcome measures that
assessed symptoms such as pain
and heaviness. In one study pneumatic compression produced a reduction
in lymphedema volume that was 18% greater than the reduction produced
by elastic compression;41. in
another study no difference was
detected between elastic compression and pneumatic compression.36.No
comparative
studies have been published to determine the most effective pumping time,
pressure levels or
kind of pump. There is a suggestion,44. but not
unanimous agreement,43. that sequential, multichambered
pumps are
more effective than monochambered pumps. The former produce a linear pressure
wave from
distal to proximal portions of the limb that reduces the
tendency of fluid to collect in the hand. There are
several
commercially available pumps, ranging in complexity and cost. Most pumps used
by therapists,
clinics and consumers are complex and cost several
thousand dollars. Pump therapy is contraindicated in the
presence
of active infection or deep vein thrombosis in the limb.35. Dini D, Del Mastro
L, Gozz A, Lionetto
R, Garrone O, Forno G, et al. The role of
pneumatic compression in the treatment of postmastectomy
lymphedema. A randomized phase III study. Ann Oncol 1998;9:187-91.36.
Bertelli G, Venturini M, Forno
G, Macchiavello F, Dini D. An
analysis of prognostic factors in response to conservative treatment of
postmastectomy lymphedema. Surg Gynecol Obstet 1992;175:455-60.37.
Kim-Sing C, Basco VE.
Postmastectomy lymphedema treated with the
Wright linear pump. Can J Surg 1987;30:368-70.38. Pappas
CJ,
O'Donnell TF. Long-term results of compression treatment for lymphedema. J Vasc
Surg
1992;16:555-62.39. Klein MJ, Alexander MA, Wright JM, Redmond
CK, LeGasse AA. Treatment of
adult lower extremity lymphedema with
the Wright linear pump: statistical analysis of a clinical trial. Arch
Phys Med Rehabil 1988;69:202-6.40. Raines JK, O'Donnell TF, Kalisher L,
Darling RC. Selection of
patients with lymphedema for compression
therapy. Am J Surg 1977;133:430-7.41. Swedborg I. Effects of
treatment with an elastic sleeve and intermittent pneumatic compression
in post-mastectomy patients with
lymphedema of the arm. Scand J
Rehabil Med 1984;16:35-41.42. Richmand DM, O'Donnell TF Jr,
Zelikovski A. Sequential pneumatic compression for lymphedema. Arch
Surg 1985;120:1116-9.
Medical supply stores can order pumps for you. Two
places I have heard of that works with insurance plans
is:http://advancedrehabtechnologies.net/
and
http://www.absolutemedical.net/
With all the different insurance
plans out there, getting reimbursed is complicated. Many standard Medical
Equipment companies may not have the knowledge to get the
multi-chambered, gradient pumps covered.
And they are
expensive.Medicare does require that conservative methods be tried for at least
thirty days
before the best equipment. And there are different
requirements for different types of Lymphedema. Cancer
patients
have different standards than do patients w/ venous ulcer problems. At my
company, Advanced
Rehab Technologies, Inc. we often put a standard,
non gradient pump on a patient for a month trial, so as to
meet
Medicare expectations. If the patient fails, or has problems with this pump,
then we can move forward
with the more advanced pump.
Soundsbackwards , but that is the insurance issue today.As always, pumps
are not the total solution. Follow your medical professionals advice
and follow a multi-faceted approach to
dealing with it.Sincerely,
Dan Dulnikowski of Advanced Rehab Technology**Dan is a valued member of
Lymphland International Lymphedema Support Online.
Absolute
Medical, Inc. is a durable medical equipment company that is committed to
providing the best in
home compression pump therapy for people with
chronic edemas including primary and secondary
lymphedema, chronic
venous insufficiency, long-standing (venous return) ulcers, and other vascular
disorders.We also offer...Insurance coverage verification for all
varieties of insurance including
Medicare.Direct insurance billing
for qualifying patients.At-home equipment installation and
set-up.Comprehensive instruction by qualified personnel.And 24-hour
customer service.
Influence of Age and Gender on Human Lymphatic Pumping Pressure in the
Leg. This Japanese study published in Lymphology 44 (2011) 113-120
found that the age-related decrease in lymphatic pumping pressure was more
marked in females of postmenopausal age.