Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Complete Decongestive Therapy (CDT)

Policy #:07.06.01b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Complete decongestive therapy (CDT) is considered medically necessary and, therefore, covered when all of the following medical necessity criteria are met:
  • The individual has a diagnosis of lymphedema.
  • The individual is symptomatic (e.g., numbness, tightness, stiffness, heaviness, and limb swelling) for lymphedema with functional limitation (e.g., difficulty dressing, decreased walking endurance, difficulty swallowing, difficulty speaking, compromised airway).
  • The individual or caregiver is able to comprehend, comply, and continue the treatment regimen independently in the home setting.
  • The services will be performed by an eligible healthcare provider who has received specialized training in this form of treatment.

The repetitive performance of CDT services to prevent regression or the point at which the individual is unlikely to attain further functional ability from additional therapy are considered maintenance. Maintenance therapy is not covered by the Company because it is a benefit contract exclusion. Therefore, it is not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. When an individual is receiving CDT, the initial and subsequent medical record documentation must include the following components:
  • Documentation of the diagnosis of lymphedema, including the individual's symptoms, the cause of lymphedema, and whether there has been any prior treatment.
  • Initial measurements (e.g., measurements of affected and unaffected regions of the body), or landmark measurements (e.g., chin to top of head or neck on a face diagram) or other confirmation of lymphedema (e.g., serial photographs, especially when measurements cannot be obtained.
  • Subsequent measurements (e.g., measurements of affected and unaffected areas of the body) or other confirmation (e.g., serial photographs) of lymphedema and progress reports showing a reduction in size.
  • Progress reports addressing the expected outcome, as well as the expected duration of treatment.
  • A response from the individual or the individual's caregiver confirming their understanding of the education and ability to take on responsibilities for the treatment: the ongoing progress reports must document the the individual's or the caregiver's response to, and understanding of, the education and the ability to continue the treatment regimen in the home setting.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, CDT services are covered under the medical benefits of most of the Company’s products when medical necessity criteria in the medical policy are met.

Benefits for all services related to outpatient physical therapy (PT)/occupational therapy (OT) are provided to members in accordance with the benefit contract and vary by product and group. For specific coverage criteria regarding limits and existing contractual exclusions, individual member benefits must be verified.

MANDATES

Postmastectomy lymphedema treatment is a federally mandated benefit for Commercial members; this policy meets applicable state and federal mandates.

Description

The lymphatic system has two primary immunologic functions: activating the inflammatory response and controlling infections. In addition, the lymphatic system drains protein-containing fluid from body tissue and conducts it in a unidirectional flow to the circulatory system. Interruption in this drainage system results in the swelling of a body part, usually an extremity. This is referred to as lymphedema, an abnormal accumulation of lymphatic fluid.

There are two types of lymphedema: primary and secondary. Primary lymphedema is an inherited malformation of the lymph vessels and/or lymph node development. It is less common than secondary lymphedema and may be due to conditions such as Milroy's disease or congenital deformities. Secondary lymphedema is acquired and occurs from damage to the lymphatic network. Damage to formerly functioning lymphatic channels may be caused by infection, physical trauma, the surgical removal of regional lymph nodes, post-radiation, or can be a result of lymph node obstruction due to malignancy. Lymphedema following breast cancer has been primarily studied; however, lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer, and sarcoma. As a result, lymphedema can occur in regions of the body that include the upper and lower extremities, genitalia, neck, and trunk. Occasionally, chronic swelling and lymph displacement will cause the skin to develop an open wound. The use of compression bandaging on such wounds can assist with healing as it promotes venous circulation and helps improve the reabsorption of fluid in the tissue spaces.

Currently, there is no cure for lymphedema. Treatment consists of a multimodality regimen called complete decongestive therapy (CDT), sometimes referred to by other terms, which include, but are not limited to, complex decongestive therapy, combined decongestive therapy, complex decongestive physiotherapy, and decongestive lymphatic therapy. When administered properly, CDT assists in the removal of lymph drainage from congested areas and decreases swelling; enhances the individual's functional status (e.g., activities of daily living, mobility); reduces skin fibrosis and improves skin condition; relieves discomfort; and reduces the risk of cellulitis and Stewart-Treves syndrome, a rare form of angiosarcoma. A CDT program typically consists of the following components:
  • Skin care
  • Manual lymph drainage (MLD)
  • Multilayer, short-stretch compressive bandaging of the affected area
  • Lymphatic exercise
  • Education in lymphedema self-management and the use of compression garments.

CDT consists of two phases: the initial reductive phase (Phase I) followed by a maintenance phase (Phase II). In Phase I, the main goals are reducing the size and improving the condition of the skin of the affected body part. The site, stage, severity, and complexity of the individual's lymphedema determine the form of management program that will be required. The average duration of the initial reductive phase is one to two weeks, depending on the condition of the individual and the progress of therapy. During the time of the initial reductive phase, treatment should be evaluated continuously and appropriate alterations made according to the needs of the individual and the effectiveness of the selected regimen. Adequate time must be allowed for education and instruction so the individual or caregiver can independently continue therapy in the home setting. Phase II, the maintenance phase, is the ongoing, individualized self-management phase that ensures the gains of Phase I are maintained in the long term. The self-management program typically includes self-lymph drainage (e.g., simple lymphatic drainage), lymphatic exercises, a skin care regimen, and compression bandages or garments that the individual or caregiver learns to apply. The maximum benefits of CDT are only expected if the individual continues treatment at home.
References


Agency for Healthcare Research and Quality (AHRQ). Technology Assessment: Diagnosis and Treatment of Secondary Lymphedema. [Centers for Medicare and Medicaid Services Web site]. 05/28/2010. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id66aTA.pdf. Accessed May 11, 2018.

American Cancer Society (ACS). Women's Health and Cancer Rights Act. [ACS Web site]. Revised 01/16/2014. Available at: https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/health-insurance-laws/womens-health-and-cancer-rights-act.html. Accessed May 11, 2018.

American Cancer Society. Lymphedema. [American Cancer Society Web site]. Revised 07/07/2016. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/lymphedema.html. Accessed May 11, 2018.

Bohmert J, Moffat M, Zadai C. §6H: Impaired circulation and anthropometric dimensions associated with lymphatic systems disorders. In: American Physical Therapy Association, eds. Guide to Physical Therapy Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001: 569-585.

Bozkurt M, Palmer LJ, Guo Y. Effectiveness of decongestive lymphatic therapy in patients with lymphedema resulting from breast cancer treatment regardless of previous lymphedema treatment. Breast J. 2017;23(2):154-158.

Dayes IS, Whelan TJ, Julian JA, et al. Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer. J Clin Oncol. 2013;31(30):3758-63.

Do JH, Choi KH, Ahn JS, et al. Effects of a complex rehabilitation program on edema status, physical function, and quality of life in lower-limb lymphedema after gynecological cancer surgery. Gynecol Oncol. 2017;147(2):450-455.

European Wound Management Association (EWMA). Lymphoedema bandaging in practice. 2005. Medical Education Partnership. [EWMA Web site]. Available at: http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2005__Lymphoedema/English_focus_doc_05.pdf. Accessed May 11, 2018.

Ezzo J, Manheimer E, McNeely ML, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database of Systematic Reviews. 2015; 5: CD003475, DOI: 10.1002/14651858. [The Cochrane Library Web site]. 05/21/15. Available at: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003475.pub2/full. Accessed May 11, 2018.

Feely MA, Olsen KD, Gamble GL, et al. Cutaneous lymphatics and chronic lymphedema of the head and neck. Clin Anat. 2012;25:72-85.

Gradalski T, Ochalek K, Kurpiewska J. Complex decongestive lymphatic therapy with or without Vodder II manual lymph drainage in more severe chronic postmastectomy upper limb lymphedema: a randomized noninferiority prospective study. J Pain Symptom Manage. 2015;50(6):750-7.

Hacard F, Machet L, Caille A, et al. Measurement of skin thickness and skin elasticity to evaluate the effectiveness of intensive decongestive treatment in patients with lymphoedema: a prospective study. Skin Res Technol. 2014;20(3):274-81.

Howell D, Ezzo J, Bily L, Johansson K. Complete decongestive therapy for lymphedema following breast cancer treatment (Protocol). The Cochrane Database of Systematic Reviews. 2002;1: CD003475, DOI: 10.1002/14651858. [The Cochrane Library Web site]. 01/21/02. Available at: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003475/abstract. Accessed May 11, 2018.

Huit M. Clinical practice development: lymphoedema in patients treated for head and neck cancer. J Lymphoedema. 2011;6(1):50-57.

Kim do S, Sim YJ, Jeong HJ, et al. Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial. Arch Phys Med Rehabil. 2010;91(12):1844-8.

International Society of Lymphology (ISL). 2009 consensus document of the International Society of Lymphology: the diagnosis and treatment of peripheral lymphedema. [ISL Web site]. 2009. Available at: http://www.u.arizona.edu/~witte/2009consensus.pdf. Accessed May 11, 2018.

Lewin JS, Hutcheson KA, Barringer DA, et al. Preliminary experience with head and neck lymphedema and swallowing function in patients treated for head and neck cancer. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2010;19(2):45-52.

Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. London: MEP Ltd, 2006. Available at: http://www.woundsinternational.com/pdf/content_175.pdf. Accessed May 11, 2018.

Mayrovitz HN. The standard of care for lymphedema: current concepts and physiological considerations. Lymph Res Biol. 2009;7(2):101-108.

McNeely M, Campbell OM, et al. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database System Rev. 2010; 6:CD005211.

Mehrara, B. Breast cancer-associated lymphedema. 03/12/18. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed May 11, 2018.

Mehrara, B. Clinical staging and conservative management of peripheral lymphedema. 05/24/17. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed May 11, 2018.

Melam GR, Buragadda S, Alhusaini AA, et al. Effect of complete decongestive therapy and home program on health- related quality of life in post mastectomy lymphedema patients. BMC Womens Health. 2016;16:23.

Melgaard D. What is the effect of treating secondary lymphedema after breast cancer with complete decongestive physiotherapy when the bandage is replaced with Kinesio Textape? - A pilot study. Physiother Theory Pract. 2016;32(6):446-451.

National Lymphedema Network (NLN). Position statement of the National Lymphedema Network:.Diagnosis and treatment of lymphedema. [NLN Web site]. 02/2011. Available at: http://www.lymphnet.org/pdfDocs/nlntreatment.pdf. Accessed May 11, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35036: Therapy and rehabilitation services (PT, OT). [Novitas Solution Web site]. Original: 10/01/15. (Revised: 03/29/18). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35036&ver=80&Date=&DocID=L35036&bc=iAAAABAAAAAA&. Accessed May 11, 2018.

Oremus M, Dayes I, Walker K, et al. Systematic review: conservative treatment for secondary lymphedema. BMC Cancer. 2012;12:6.

Pekyavaº NÖ, Tunay VB, Akbayrak T, et al. Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study. Eur J Oncol Nurs. 2014;18(6):585-90.

Piso DU, Eckardt A, Liebermann A, et al. Early rehabilitation of head-neck edema after curative surgery for orofacial tumors. Am J Phys Med Rehabil. 2001;80(4):260-269.

Preston NJ, Seers K, Mortimer PS. Physical therapies for reducing and controlling lymphoedema of the limbs (Review). The Cochrane Database of Systematic Reviews.2004;4: CD003141.

Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of the role of adjunctive intermittent pneumatic compression. Cancer. 2002; 95:2260-2267.

Tambour M, Tange B, Christensen R, et al. Effect of physical therapy on breast cancer related lymphedema: protocol for a multicenter, randomized, single-blind, equivalence trial. BMC Cancer. 2014;14:239.

United States (US) Department of Labor (DOL). Fact Sheet: Women’s Health and Cancer Rights Act.[US DOL Web site]. Available at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/whcra.pdf. Accessed May 11, 2018.

Up to Date. Lymphedema: Prevention and treatment. 06/16/2014. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. [The link to this reference is no longer active on the UpToDate Web site.]. Accessed October 10, 2016.

Vignes S, Blanchard M, Arrault M, et al. Intensive complete decongestive physiotherapy for cancer-related upper-limb lymphedema: 11 days achieved greater volume reduction than 4. Gynecol Oncol. 2013;131(1):127-30.

Whitaker J. Best practice in managing scrotal lymphoedema. Br J Community Nurs. 2007;12(10):S17-18,20-21.

Zuther JE, Norton S. Lymphedema Management: The Comprehensive Guide for Practitioners. 3rd edition. Head and Neck Lymphedema. 2009. Stuttgart, Germany; New York, NY. Thieme.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

97110, 97140


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

I89.0 Lymphedema, not elsewhere classified

I97.2 Postmastectomy lymphedema syndrome

Q82.0 Hereditary lymphedema



HCPCS Level II Code Number(s)



THE FOLLOWING CODE IS USED TO REPRESENT ALL COMPLETE DECONGESTIVE THERAPY (CDT) SERVICES

S8950 Complex lymphedema therapy, each 15 minutes


Revenue Code Number(s)



0420 General Classification/Physical Therapy

0430 General Classification/Occupational Therapy

Coding and Billing Requirements


Cross References


Policy History

Revisions to 07.06.01b
06/20/2018Effective 6/20/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Complete Decongestive Therapy (CDT).


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2014
Version Issued Date: 12/30/2013
Version Reissued Date: 06/20/2018

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