Medical necessity justification helps retailers and suppliers bill confidently and reduce patients’ out-of-pocket expenses for necessary products. This documentation comes from treating practitioners– that’s YOU!
Without proper prescription, your patient may not receive the products they need to improve their symptoms.
Clinical notes and medical record documentation needs to support that a certain product or accessory is necessary to support the effectiveness of the product for the patient.
Example of comprehensive clinical notes for a truncal compression garment:
Patient presents with mild, unilateral, left, breast lymphedema that extends toward the axilla, secondary to tumor resection in 2020. Patient requires a standard-fit, circular knit, truncal compression garment for daytime use. Quantity 3 of each item needed for proper wash and wear.
| ✔ | Lymphedema stage/severity by body part |
| ✔ | Medical necessity for prescribed garment |
| ✔ | Compression garment type prescribed to treat that body part |
| ✔ | (If a custom garment is ordered, notes must indicate why a standard-fit garment is not indicated for the patient) |
*Examined in accordance to RAL-GZ 387/1:2008-01
Finding the right level of support and the proper fit is made easy with ABC compression solutions.
MEDIUM TO HIGH LEVEL COMPRESSION
Compression: Medium
Compression: Medium
Compression: High
LOW TO MODERATE LEVEL COMPRESSION
Compression: Low
Compression: Low to Moderate
Compression: Moderate
| Q82.0 | Hereditary lymphedema |
| I89.0 | Lymphedema, not elsewhere classified |
| I97.2 | Postmastectomy lymphedema syndrome |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
| DAYTIME | A6589 Gradient pressure wrap with adjustable straps, bra, each A6568 Gradient compression garment, torso and shoulder, each A6569 Gradient compression garment, torso and shoulder, custom each |
| NIGHTTIME | A6528 Gradient compression garment, bra, for nighttime use, each A6529 Gradient compression garment, bra, for nighttime use, custom, each |
FAQs
Per the LTA ruling: "Gradient compression garments meant for daytime provide a higher level of compression, and use of them while sleeping could cause new or additional damage to the affected tissue. Gradient compression garments made for nighttime use or times of low activity offer milder compression and are less snug against the skin. Wearing gradient compression garments designed for nighttime use may also help with skin abnormalities resulting from lymphedema and can help prevent a phenomenon called “creeping refill,” where swelling reoccurs during sleep."
Read the full ruling here
You may have a patient who requires our 520 bra for daytime and another patient who requires that same bra for their nighttime depending on treatment and maintenance plan that you outline for their needs.
Truncal lymphedema is sometimes masked by obesity or existing tissue and skin folds. Additionally, the patient may be uncomfortable disrobing for an exam and/or the practitioner may be hesitant to request the patient to undress. And, relying on the patient to report their symptoms like tenderness, tingling, or heat isn't reliable due to the patient's loss of sensation in those areas.
"Since truncal lymphedema is difficult to identify, it is recommended to assume truncal involvement when extremity lymphedema is present, such as the arm." 1
1 Joachim Ernst Zuther, Steve Norton. Lymphedema Management: The Comprehensive Guide for Practitioners. Thieme, 2017.
It is the manufacturer's responsibility to register their lymphedema compression garments in the FDA database and to show proof of compression. The FDA database is a public website where you can search by manufacturer to check their products. PDAC verification is not a requirement for truncal lymphedema compression garments.
Make sure your claim includes a detailed narrative of the item, the purpose, and the supplier price list amount. The supplier price list (PL) amount is NOT the MSRP, and it is NOT the cost to the supplier. It is the maximum amount suppliers “sell” their products to customers (patients).