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Lymphland International Lymphedema Online
| CIGNA MEDICAL COVERAGE POLICY The following Coverage Policy applies to all plans administered by CIGNA Companies including plans administered by Great-West Healthcare, which is now a part of CIGNA. Subject Lymphedema Pumps and Sleeves Effective Date............................5/15/2009 Next Review Date......................5/15/2010 Coverage Policy Number................ 0354 HealthCare benefit plans as well as benefit plans formerly administered by Great-West Healthcare. Please note, the terms of a participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a participant’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a participant’s benefit plan document always supercedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. Proprietary information of CIGNA. Copyright ©2009 CIGNA Coverage Policy Coverage for the treatment of lymphedema, including lymphedema pumps and sleeves, may be governed by federal and/or state mandates. Lymphedema compression sleeves are generally covered under the core medical benefits of the plan. Coverage for lymphedema pumps used in the home is subject to the terms, conditions and limitations of the applicable benefit plan’s Durable Medical Equipment (DME) benefit and schedule of copayments. Please refer to the applicable benefit plan document to determine benefit availability and the terms, conditions and limitations of coverage. Under many benefit plans, coverage for DME is limited to the lowest-cost alternative. Unless excluded from the benefit plan, the following conditions of coverage apply. CIGNA covers the purchase of a lymphedema compression sleeve as medically necessary for the treatment of lymphedema. CIGNA covers a standard lymphedema pump as medically necessary for the treatment of intractable lymphedema when there is failure of a four-week trial of conservative medical management including ALL of the following: • home exercise program Page 1 of 10 Coverage Policy Number: 0354 • limb elevation • compression bandage or compression garment use When a lymphedema pump has been found to be medically necessary according to the above criteria, CIGNA covers the following lymphedema pumps as medically necessary: • nonsegmental/segmental (HCPCS codes E0650, E0651) • segmental with calibrated gradient pressure (HCPCS code E0652), when there is evidence of BOTH of the following: ?? failure of relief with a nonsegmental or segmental device ?? documented need for specified pressure to a localized area (e.g., scar tissue, ulcer) CIGNA does not cover two-phase lymph preparation and drainage therapy devices/systems because they have not been demonstrated to be superior to standard segmented, calibrated gradient systems and are thus not medically necessary. CIGNA does not cover chest and/or trunk pneumatic appliances for use with lymphedema pumps because they are considered experimental, investigational or unproven. General Background Lymphedema is a failure of the lymphatic transport system resulting in the accumulation of lymphatic and edema fluid in the soft tissue. Under normal circumstances, the lymphatic system regulates tissue fluid balance by maintaining equilibrium between tissue fluid filtration and reabsorption. This is accomplished through the drainage of excess fluid containing protein, lipids, microorganisms, cells and debris from the tissue, with the fluid being filtered and returned to the bloodstream. Primary lymphedema is a result of congenital defects of the lymphatic system and is rare. Secondary lymphedema is acquired and due to an obstruction or interruption in the lymphatic system. In the United States, the most common causes of lymphedema are cancer and treatment related to cancer. Patients undergoing surgery for breast cancer that includes node dissection or axillary radiation therapy are at high risk of developing lymphedema. The goals of lymphedema treatment are to decrease the excess volume as much as possible and maintain the limb at its smallest size. Lymphedema Sleeves Compression garments or sleeves have been widely used in the treatment of lymphedema. They are used alone or in combination with other treatments, including lymphedema pumps and complex lymphedema treatment (CLT). They are used for the purpose of preventing an increase in lymphedema and maintaining the reduction of lymphedema after treatment. They may be custom-fitted or prefabricated and have varying degrees of elasticity. The type of sleeve used is dependent on the size needed and whether the patient correctly fits the parameters of the prefabricated garment. It is important that the garment fit correctly and provide adequate, graduated compression. A glove or gauntlet may also be used if lymphedema is present in the hand. The sleeve will usually need replacement when elasticity is lost, approximately every 4–6 months. Types of compression sleeves include Jobst® Armsleeve (BSN-JOBST, Inc., Charlotte, NC), Juzo® compression arm sleeves (Juzo, Cuyahoga Falls, OH), and FarrowWrap® (Farrow Medical Innovations, Bryan, TX). The ReidSleeve® (Peninsula Medical, Inc., Scotts Valley, CA) is a custom-fitted, non-elastic sleeve that provides compression to assist in flow of lymphatic fluid. According to the manufacturer’s website, the sleeve contains a foam insert and works by applying high and low pressure to different parts of the affected area. The high-pressure zones force excess fluid into the areas under lower pressure, forming channels by which the lymphatic fluid can be removed through the lymphatic and venous system. The Contour® and Optiflow® sleeves are made by the same manufacturer as the ReidSleeve and use the same technology but are lighter sleeves that are intended for patients with mild to moderate lymphedema. ArmAssist® and LegAssist® (MedAssist Group, Tampa, FL) are other custom- fabricated, non-elastic compression sleeves. CircAid® (CircAid Medical Products Inc., San Diego, CA) is a non-elastic compression sleeve that is available prefabricated and custom-fitted. Page 2 of 10 Coverage Policy Number: 0354 nonsegmented pumps that provide even pressure throughout the limb; however, they allow backflow of lymphatic fluid. This can cause an increase of fluid in the distal arm. Newer devices have multiple segmented chambers and have the ability to provide sequential compression. Multiple-chamber units typically inflate from distal to proximal, producing a wave of pressure that ascends to the extremity, with the same pressure being delivered in each garment section. Proponents contend that this wave brings edema fluid with it, allowing the retained fluid to be brought to functional lymphatics. When provided as the sole treatment modality, lymphedema pumps are generally reserved for patients with intractable lymphedema for whom an adequate trial of more conservative medical treatment has failed. Established conservative medical treatments include the use of bandaging and compression garments, limb elevation, and home exercise programs. Segmental pumps that have a calibrated gradient pressure feature are typically used only in patients who require limited pressure to be applied to a specific area (e.g., significant scars or the presence of contracture or pain caused by the clinical condition). Lymphedema pumps include, but are not limited to, the following: • Nonsegmented pneumatic compressor: This device has a single outflow port on the compressor. Although there is a single tube, air from this single tube may be transmitted to a sleeve with multiple compartments and would be functionally equivalent to a segmented pneumatic compressor with a segmented sleeve; or the device can be used with a nonsegmented sleeve. An example of this type of pump is the Huntleigh Flowtron® Hydroven 3 Pump (Huntleigh, Eatontown, NJ) • Segmented pneumatic compressor: This device has multiple outflow ports on the compressor that lead to distinct segments on the appliance, which inflates in a sequential manner. ?? A segmented device without calibrated pressure is one in which either (a) the same pressure is present in each segment, or (b) there is a predetermined pressure gradient in successive segments but no ability to individually set or adjust pressures in each of the several segments. The pressure is usually set by a single control on the distal segment. Examples of models include: Wright 51 Non-Gradient (Wright Therapy Products, Oakdale, PA), KCI Jobst System 7500 Sequential Compression Pump (BSN-JOBST, Inc., Charlotte, NC). ?? A segmented device with calibrated gradient pressure is characterized by a manual control on at least three outflow ports that can deliver individually determined pressure to each segmental unit. Examples include: Chattanooga 4333 Multi 6 Compression Therapy System (Chattanooga Group, Chattanooga, TN), Talley Multipulse™ 500 sequential compression system (Talley Medical USA, Lansing, MI), Wright 52 Gradient (Wright Therapy Products, Oakdale, PA) There is no consensus in the scientific literature on optimal pump selection and use. The scientific evidence supporting the use of pneumatic pumps as a solitary treatment modality for lymphedema is extremely limited and of poor quality. There is some evidence to indicate that using pumps as an adjunct to CLT has beneficial effects on the outcome of the therapy. Comparative studies evaluating the most effective pumping times, pressure levels or kind of pump are lacking (Harris, 2001). Optimal pressure ranges, inflation/deflation cycles, and length and frequency of individual pumping sessions have not been established (Brennan, 1998; Kerchner, et al., 2008). There is some evidence to suggest that sequential multi-chambered pumps are more effective than single-chambered pumps. One randomized trial attempted to evaluate pneumatic compression pumps for the treatment of lymphedema. Dini et al. (1998) randomized 80 post-mastectomy women to either intermittent pneumatic compression or no treatment. Women in the treatment group underwent a two-week cycle of five pump sessions per week, followed by a five-week break in treatment and then another two-week cycle of treatment. There was no statistically significant difference in response rates between the two groups. The authors concluded that pneumatic compression pumps have a limited role in the management of patients with lymphedema. A systematic review of the common conservative therapies for arm lymphedema secondary to breast cancer treatment was conducted by Mosely et al. (2007). The review included the following treatments: complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, Page 3 of 10 Coverage Policy Number: 0354 compression bandaging and garments. The review found that the more intensive and health professional based therapies, such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally yielded the greater volume reductions. Self-initiated therapies such as compression garment wear, exercise and limb elevation were found to yield a lesser volume reduction. The review included randomized, controlled, parallel and cross-over, case-control and cohort studies. A meta-analysis could not be performed due to the treatment and data heterogeneity. Five studies were included that examined pneumatic pump therapy. Two of these studies demonstrated that volume reduction could be achieved from pump therapy alone, although one study utilized higher pressure that was usually recommended. Three studies demonstrated that better results in volume reduction were achieved when the pneumatic pump was used in combination with other treatments, including: manual lymphatic drainage, compression garments and self massage. In addition, it was noted that three studies demonstrated that continuing pump therapy or wearing a compression garment were beneficial in maintaining the reduction in volume. The review concluded that, "Despite the range of positive outcomes identified in this review, the evidence to support them is, in some instances, poor. Therefore, there is still a need for large scale, high level clinical trials in this area." Two-Phase Lymph Preparation and Drainage Therapy Devices Newer lymphedema devices/systems have been developed that provide treatment in two phases—a preparatory and a drainage phase. In addition to leg and arm garment/appliances that are used with standard lymphedema pumps, these devices include the use of unique garments/appliances to be worn on trunk, chest, and torso area. Two-phase lymph preparation and drainage therapy devices/systems include: • Flexitouch® Lymphedema System (Tactile Systems Technology, Minneapolis, MN): This device consists of an electronic controller unit and patented garments, worn on the trunk, chest, and upper and/or lower affected extremities and connected to the controller unit by tubing harnesses. According to the manufacturer website, the system is a two-phase lymph preparation and drainage therapy system device for treatment of primary lymphedema, post-mastectomy lymphedema, edema following sports injuries, post-immobilization edema, and venous insufficiencies. The website notes that the system provides action in two phases: lymph preparation and lymph drainage. It is proposed that this two- phase action utilizes a light, therapeutic sequential action to gently prepare the trunk and extremities for lymph evacuation and to assist in draining excess fluid from the limb to the venous system. The system consists of programmable, segmented pneumatic compression device with calibrated gradient pressure along with patented separate trunk and limb components that, when combined, consist of up to 32 separate chambers. The system provides treatment for truncal lymaphatics in addition to the affected limb. The manufacturer notes that this system has been shown to be similar to self-administered CLT and allows for home treatment. • Lympha Press Optimal™ Lympha Press® Plus (Mego Afek, Manalapan, NJ): According to the vendor website, this device includes "pretherapy™, which is based on the principles of manual lymph drainage. It is used with unique torso garments. These include the Lympha Pants II™ for complete treatment of abdominal and genital lymphedema, or the Lympha Jacket II™ for complete treatment of truncal lymphedema. • NormaTec PCD (NormaTec Industries LLC, Newton Center, MA): According to the vendor website, this device provides an exclusive "pre-fill" inflation sequence with custom-forms boots/sleeves for each patient. There are also pelvic/scrotal appliances available for use with this device Ridner et al. (2008) conducted a study to compare treatment protocol adherence, satisfaction and perceived changes in emotional and functional status between patients with lymphedema using the home- based Flexitouch system. One hundred fifty-five patients were included in the study—93 with cancer related symptoms and 62 with noncancer-related lymphedema. A survey was completed before treatment and a post-therapy survey was completed during the maintenance phase of the protocol. Participants without cancer were more adherent to the prescribed protocol. Both groups were found to be satisfied with the system, perceived it to be effective, and reported improvement in physical and emotional status. The limitations of the study included: post-therapy questionnaires were obtained from 64% of the participants, the findings in this study were self-reported, and there was no control group. Wilburn, et al. (2006) reports on a prospective, randomized crossover study involving 10 patients that compared the efficacy of the Flexitouch to massage for treatment of lymphedema of the arm (Each phase included self-administered treatment with Flexitouch or massage for one hour daily for 14 days. Each phase was preceded by Page 4 of 10 Coverage Policy Number: 0354 a one-week treatment washout, which included use of a garment only. It was noted that post-treatment arm volume was reduced with the Flexitouch, but not with massage. The device appeared to be well- tolerated by patients. This study was limited by the small sample size and short duration of treatment. In addition, there was no comparison to standard pneumatic lymphedema pumps or complex lymphedema therapy. The published evidence does not demonstrate that the use of two-phase lymph preparation and drainage therapy devices/systems is superior to standard segmented, calibrated gradient pumps/systems. In addition evidence is lacking to support the treatment of truncal, abdominal or torso appliances for use with lymphedema pumps. It has not been demonstrated through well-designed trials published in the peer-reviewed scientific literature whether there is incremental clinical value in using torso components in addition to limb appliances. Impact on meaningful health outcomes through the added use of these torso/trunk components is not known at this time. Which patients would most benefit from these devices has not been clearly defined in the literature. U.S. Food and Drug Administration (FDA): Lymphedema pumps are approved under the U.S. Food and Drug Administration (FDA) 510(k) process. They are classified as Class II devices, cardiovascular therapeutic devices, and compressible limb sleeves. Manufacturers include, but are not limited to: Advantage (Microtek Medical Inc., Jacksonville, FL); Bio Compression Inc. (Moonachie, NJ); Thera- Con (Bethesda, MD); Kendall (Tyco Healthcare Group, LP, Mansfield, MA); Talley (Talley Group Ltd., Romsey, UK); Jobst (BSN-JOBST, Inc., Charlotte, NC); and Wright Linear Pump, Inc. (Oakdale, PA). The Flexitouch system received initial 510(k) approval from the FDA as a class II device under the name Biotouch® Massage Therapy System (Tactile Systems Technology, Inc., Shakopee, MN), as a compressible limb sleeve. The 510(k) summary notes that the predicate device is the Progressive Medical Technology, Inc., Multipulse Sequential Compression Unit. The summary notes that the intended use is to treat patients at home under medical supervision for the following indications: primary lymphedema, post-mastectomy edema, edema following trauma or sports injury, post-mobilization edema, venous insufficiencies, and lymphedema (FDA, 2002). In 2006, the Flexitouch system received 510(k) approval as powered inflatable tube massager, Class II device. The predicate devices listed in this 510(k) summary are the BioCompression Systems, model SC-3008 sequential circulator, Medical Compression Systems Ltd. Active Care® system, and Tactile Systems Technology, Inc Flexitouch system. In addition to the above-noted indications, the summary lists the following indications: reducing wound healing time, and treatment and assistance in healing: stasis dermatitis; venous stasis ulcers; arterial and diabetic leg ulcers (FDA, 2006). Professional Societies/Organizations The National Lymphedema Network (NLN): The NLN published a position statement regarding treatment of lymphedema (NLN, 2006). This document indicates that CLT is the current international standard of treatment for managing lymphedema. Regarding the use of lymphedema pumps, it notes that while the use of pumps is not a component of conventional CLT, they may be used as an adjunct to CLT. Compression garments are essential for long-term control of lymphedema volume. The patient should be fitted with a compression garment following maximal volume reduction resulting from Phase I of CLT. Alternative nonelastic compression devices are often useful adjuncts for nighttime compression during CLT or are utilized during the Phase II of CLT. International Society of Lymphology (ISL): In 2003 the ISL published a consensus document regarding the diagnosis and treatment of peripheral lymphedema (ISL, 2003). The document makes the following comments regarding lymphedema treatment: • Treatment of peripheral lymphedema is divided into conservative (i.e., nonoperative methods) and operative methods. Both methods include an understanding that meticulous skin hygiene and care is of extreme importance to the success of all treatment approaches. • Intermittent pneumatic compression is included in the document as a standard treatment for lymphedema. After external compression therapy, form-fitting stockings or sleeves are used to maintain edema reduction. • An assessment should be made of limb volume before, during and after treatment. Treatment outcomes should be reported in standardized manner in order to assess effectiveness of treatment protocols. Summary Page 5 of 10 Coverage Policy Number: 0354 While there is limited scientific evidence in the form of well-designed clinical trials supporting the use of lymphedema pumps and sleeves, the practicing medical community generally considers them safe and effective nonsurgical options for the treatment of lymphedema. The use of a lymphedema pump is appropriate after a four-week trial of conservative medical management that includes exercise, elevation and compression garments. Standard segmental lymphedema pumps with calibrated gradient pressure are appropriate for patients with a failure of relief with use of a nonsegmental or segmental device and a documented need for specified pressure to a localized area (e.g., scar tissue, ulcer). Two-phase lymph preparation and drainage therapy devices/systems have not been demonstrated to be superior to standard segmented, calibrated gradient systems and thus are considered not medically necessary. The clinical effectiveness of garments/appliances for chest and trunk area cannot be determined and their role in the management of lymphedema has not been established. Coding/Billing Information Note: This list of codes may not be all-inclusive. Covered when medically necessary: HCPCS Codes Description E0650 Pneumatic compressor, nonsegmental home model E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure E0652† Pneumatic compressor, segmental home model with calibrated gradient pressure E0655 Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm E0660 Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg E0665 Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm E0666 Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg E0671 Segmental gradient pressure pneumatic appliance, full leg E0672 Segmental gradient pressure pneumatic appliance, full arm E0673 Segmental gradient pressure pneumatic appliance, half leg S8420 Gradient pressure aid (sleeve and glove combination), custom made S8421 Gradient pressure aid (sleeve and glove combination), ready made S8422 Gradient pressure aid (sleeve), custom made, medium weight S8423 Gradient pressure aid (sleeve), custom made, heavy weight S8424 Gradient pressure aid (sleeve), ready made HCPCS Codes Description E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest *Current Procedural Terminology (CPT) 2008 American Medical Association: Chicago, IL.®© References 1. Brennan MJ, Miller LT. Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema. Cancer. 1998 Dec 15;83(12 Suppl American):2821-7. 2. Brooks L; Health Technology Assessment Unit, Alberta Heritage Foundation for Medical Research (AHFMR). Extremity pumps for the treatment of primary peripheral edema. Technote 25. Edmonton, Alberta, Canada: AHFMR; 2001 Jan. Accessed April 15, 2009. Available at URL address: http: //www.ihe.ca/documents/tn25.pdf 3. Cannon, S. Pneumatic compression devices for in-home management of lymphedema: two case reports. Cases J. 2009 Mar 23, 224. 4. Centers for Medicare & Medicaid Services (CMS). Decision memo for lymphedema pumps (CAG- 00016N). 2001 May 3. Accessed April 15, 2009. Available at URL address: http://www.cms.hhs. gov/mcd/viewdecisionmemo.asp?id=50 5. Centers for Medicare & Medicaid Services (CMS).Transmittal 151. Revision to the coverage issues manual 60-16 - 60-19. 2002 Jan 14. Accessed April 15, 2009. Available at URL address: http://www. cms.hhs.gov/transmittals/downloads/R150CIM.pdf 6. Commonwealth of Australia. Report to the Australian Health Ministers’ Advisory Council. Review of current practices and future directions in the diagnosis, prevention and treatment of lymphoedema in Australia. February 2004. Accessed April 15, 2009. Available at URL address: http://www.msac.gov. au/internet/msac/publishing. nsf/Content/A+review+of+current+practices+and+future+directions+in+the+diagnosis% 2C+prevention+and+treatment+of+lymphoedema+in+Australia 7. Dedecker K, Waldridge I. Simulated manual lymph drainage therapy in home treatment of lymphedema. [white paper]. Tactile Systems Technology, Inc. 2005. 8. Dini D, Del Mastro L, Gozza A, Lionetto R, Garrone O, Forno G, et al. The role of pneumatic compression pumps in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 1998 Feb;9(2):187-90. 9. ECRI Institute. Hotline Response [database online]. Plymouth Meeting (PA): ECRI Institute; 2009 Mar 30. Flexitouch System for Treatment of Lymphedema. 2009 Mar 30. Available at URL address: http://www.ecri.org. 10. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst. 2001 Jan 17;93(2):96-111. 11. U.S. Federal Drug Administration (FDA). 510 (k) premarket notification: biotouch massage therapy system. KO13061. July 2002. Accessed April 15, 2009. Available at URL address: http: //www.fda.gov/cdrh/pdf/k013061.pdf Page 7 of 10 Coverage Policy Number: 0354 12. U.S. Federal Drug Administration (FDA). 510 (k) premarket notification: Flexitouch® System. K062818. October 2006. Accessed April 15, 2009. Available at URL address: http://www.fda. gov/cdrh/pdf6/K062818.pdf 13. Flexitouch® system physician information. Accessed April 15, 2009. Available at URL address: http://www.tactilesystems.com/flexitouch/physicians.html 14. Golshan M, Smith B. Prevention and management of arm lymphedema in the patient with breast cancer. J Support Oncol. 2006 Sep;4(8):381-6. 15. Hammond T. Can truncal edema be treated with pneumatic compression? National Lymphedema Network. Apr-Jun 2009. 16. Harris SR. Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema. CMAJ. 2001 Jan 23;164(2):191-9. 17. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema [consensus document of the International Society of Lymphology]. Lymphology. 2003 Jun;36(2):84-91. 18. Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008 Aug;59(2):324-31. Epub 2008 May 29. 19. Kligman L, Wong RK, Johnston M, Laetsch NS. The treatment of lymphedema related to breast cancer: a systematic review and evidence summary. Support Care Cancer. 2004 Jun;12(6):421-31. Epub 2004 Apr 17. 20. Lawenda BD, Mondry TE, Johnstone PA. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009 Jan-Feb;59(1):8- 24. 21. Macdonald JM, Sims N, Mayrovitz HN. Lymphedema, lipedema, and the open wound: the role of compression therapy. Surg Clin North Am. 2003 Jun;83(3):639-58. 22. Mayrovitz HN. Interface pressures produced by two different types of lymphedema therapy devices. Phys Ther. 2007 Oct;87(10):1379-88. Epub 2007 Aug 21. 23. Mayrovitz HN, Brown-Cross D, Mayrovitz BL., Humble-Golla A. Lymphedema: Role of Truncal Clearance as a Therapy Component. Home Health Care Management Practice 2009 0: 1084822309331484. 24. Morrell RM, Halyard MY, Schild SE, Ali MS, Gunderson LL, Pockaj BA. Breast cancer-related lymphedema. Mayo Clin Proc. 2005 Nov;80(11):1480-4. 25. Moseley A, Carati C, Piller N. A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Ann Oncol. 2007 Apr;18(4):639-46. Epub 2006 Oct 3. 26. National Cancer Institute (NCI). Lymphedema (PDQ®). Last Modified: 9/9/2008. Accessed April 15, 2009. Available at URL address: http://www.cancer. gov/cancertopics/pdq/supportivecare/lymphedema/HealthProfessional 27. National Lymphedema Network (NLN) [website]. Air Travel. May 2008. Accessed April 15, 2009. Available at URL address: http://www.lymphnet.org/lymphedemaFAQs/positionPapers.htm 28. National Lymphedema Network (NLN) [website]. Position statement of the national lymphedema network. Treatment. August 10, 2006. Accessed April 15, 2009. Available at URL address: http: //www.lymphnet.org/lymphedemaFAQs/positionPapers.htm Page 8 of 10 Coverage Policy Number: 0354 29. Peninsula Medical, Inc. ReidSleeve classic [product information]. Accessed April 15, 2009. Available at URL address: http://www.reidsleeve.com/rsleeve.htm 30. Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin. 2000 Sep-Oct;50(5):292-307. 31. Radina ME, Armer JM, Culbertson SD, Dusold JM. Post-breast cancer lymphedema: understanding women's knowledge of their condition. Oncol Nurs Forum. 2004 Jan-Feb;31(1):97-104. 32. Ridner SH. Breast cancer lymphedema: pathophysiology and risk reduction guidelines. Oncol Nurs Forum. 2002 Oct;29(9):1285-93. 33. Ridner SH, McMahon E, Dietrich MS, Hoy S. Home-based lymphedema treatment in patients with cancer-related lymphedema or noncancer-related lymphedema. Oncol Nurs Forum. 2008 Jul;35(4): 671-80. 34. Rockson SG. Lymphedema. Am J Med. 2001 Mar;110(4):288-95. 35. Sieggreen MY, Kline RA. Current concepts in lymphedema management. Adv Skin Wound Care. 2004 May;17(4 Pt 1):174-8. 36. Wilburn O, Wilburn P, Rockson SG. A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412]. BMC Cancer. 2006 Mar 29;6:84. Policy History Pre-Merger Last Review Policy Title Organizations Date Number CIGNA HealthCare 5/15/2008 0354 Lymphedema Pumps and Sleeves Great-West Healthcare 1/1/2007 07.348.01 Pneumatic Compression Devices "CIGNA" and the "Tree of Life" logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. and Great-West Healthcare of California, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. In Virginia, HMO plans are offered by CIGNA HealthCare Mid-Atlantic, Inc. All other medical plans in these states are insured or administered by Connecticut General Life Insurance Company. Page 9 of 10 Coverage Policy Number: 0354 Connecticut General Life Insurance Company has acquired the business of Great-West Healthcare from Great-West Life & Annuity Insurance Company (GWLA). Certain products continue to be provided by GWLA (Life, Accident and Disability, and Excess Loss). GWLA is not licensed to do business in New York. In New York, these products are sold by GWLA's subsidiary, First Great- West Life & Annuity Insurance Company, White Plains, N.Y. Page 10 of 10 Coverage Policy Number: 0354 |