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| Re: [Patient's Name] Member Number: [Patient's Medical Number] Group: [Medical Group] Reference #: [Denial Letter] [Patient's Name] is under my care for chronic Lymphedema (LE) that causes severe swelling (and pain) in his/her [legs and feet/arm(s)/torso/groin]. I have referred [Patient's Name] for the approved treatment for [Patient's Name]'s LE disease to the [Name of Department, Clinic or Center] This clinic is [Qualification of treatment center to which Patient was referred, e.g., "nationally recognized and respected for treatment of LE and is under the leadership of "John Doe, MD", or "staffed with therapists trained and certified in the Vodder (or Foeldi or Casley-Smith or LeDuc) method of lymphedema treatment."] The treatment for LE is officially known as Complete Decongestive Therapy (CDT). As documented in the enclosed materials, CDT includes a multi-modal treatment program. One of the essential treatment modalities is the application of compression garments/bandages, as compression is required in order to maintain the reduction of high protein edema achieved with Manual Lymph Drainage (MLD). MLD, one of the components of CDT, is performed during the clinical treatment phase and as a component of self-care in the home treatment phase. After the initial intensive program, patients must wear compression garments daily and compression bandages nightly on the affected limbs. Although it does vary to some degree, individuals with lymphedema should not remove compression from the affected area for any extended period of time, particularly when they are engaging in any physical activity such as standing or walking, or while performing therapeutic exercises as part of CDT. The following two enclosed medical journal articles describe the CDT standard treatment for LE: "Workgroup III: Diagnosis and Management of Lymphedema", Cancer, Vol. 83, No. 12, December 15, 1998, (Supplement), American Cancer Society Workshop on Breast Cancer Treatment-Related Lymphedema, New York, NY, February 20-22, 1997, pp. 2882-2885. International Society of Lymphology, Executive Committee: "The Diagnosis and Treatment of Peripheral Lymphedema, Consensus Document", Lymphology, Mar 1995, Vol. 28, pp. 113-117. Compression bandages and compression garments are an integral part of the treatment for LE. Unless [Patient's Name]'s coverage policy excludes treatment of Lymphedema, [Patient's Name] must be provided all parts of the CDT treatment. Compression garments and bandages are particularly important during the self-treatment phase following clinical treatment. As cited in the medical literature, if left untreated, LE may result in several severe consequences, including fibrosis, joint immobility, amputation and life-threatening infections that may require multiple hospitalizations for intensive intravenous antibiotic therapy. Failure to provide [Patient's Name] with proper treatment, including compression garments and bandages, predisposes him or her to these serious consequences. (Prior to being sent to the [Referred Treatment Center], [Patient's Name] experienced several onsets of lymphangitis/cellulitis, a severe infection resulting from his/her LE disease, requiring multiple extended hospitalizations.) Based on the available medical literature on [Patient's Name]'s LE condition, I am filing this physician/health care provider appeal request, specifically requesting that you provide him/her with the required [Name of Garment or Description of Bandage that was Denied], as I personally prescribed, to treat [his/her] advanced Lymphedema condition. In addition, I would like to emphasize that coverage of necessary compression bandages and garments must be ongoing. Garments are worn during waking hours and bandages at night in order to maintain the affected limb. Due to this frequent wear and necessary laundering, garments and bandages have a limited life span. Therefore, each patient must have two bandages and/or garments at all times, both of which must be replaced every six months. Thank you for your prompt attention to this request. Sincerely yours, [Physician's Name], M.D. Enclosures: [Description of Treatment Plan/Treatment Protocols, e.g.: Lymphedema-An Information Booklet by Saskia R. J. Thiadens, NLN; Lymphedema Handbook, Kaiser Permanente; or treatment program information from your treatment center] [Date] adverse decision for coverage of Jobst compression garments for [Patient's Name], submitted by [Medical Provider] "Statement of Medical Necessity" for [Name of Garment or Description of Bandage that was Denied, e.g., Custom-Made to Measure Compression Stockings, CPT Code L8220 provided by your medical supply company] Documents referred to in text |
| National Lymphedema Networks Sample Appeal letter. |
| LYMPHLAND |
