Access to Lymphedema Treatments Linked to Insurance Coverage in the US

A recent study examining insurance reimbursement practices identified limitations to coverage regarding lymphedema treatments that could potentially affect many patients in the US with this condition. Findings of the study were reported in JAMA Surgery.

The study was a cross-sectional analysis of insurance reimbursement practices regarding lymphedema treatments by the top 3 insurance companies in each state, according to market share. The study also included data maintained by the Kaiser Family Foundation on patient enrollment. Interpretations of insurance coverage were based on established medical policies made available through the websites of insurance companies and phone interviews.

In evaluating coverage, the researchers focused on treatments including nonprogrammable pneumatic compression, programmable pneumatic compression, surgical debulking, and physiologic procedures. Outcomes of interest included the level of coverage and criteria for determining coverage. The researchers analyzed coverage practices for 67 health insurance companies, which collectively accounted for 88.7% of the market share across the US.

Coverage with preauthorization was available for nonprogrammable pneumatic compression devices with 82.1% of insurers in this study. The remaining 17.9% lacked an established medical policy for this treatment. The criterion most frequently (87.3%) relied on for nonprogrammable pneumatic compression treatment was a previous trial of conservative therapy.

Coverage with preauthorization for programmable pneumatic compression also was available with 79.1% of companies. Another 17.9% of companies lacked an established medical policy for this treatment, and 3.0% of insurers reportedly had an established policy of declining coverage for this treatment.

However, availability of coverage was lower for debulking procedures, with coverage offered by 19.4% of companies for this approach, while 43.3% of companies considered debulking procedures to be investigational and would deny coverage. A lack of an established policy for debulking procedures was reported for 25.4% of companies.

Preauthorization of physiologic procedures, such as lymphovenous bypass or vascularized lymph node transfer, was covered by only 7.5% of companies. Additionally, 49.2% of companies reportedly had established policies to deny coverage for physiologic procedures. A lack of an established policy for physiologic procedures was reported for 41.8% of companies.

Enrollment into coverage for each treatment also varied considerably across states. For example, coverage of nonprogrammable pneumatic compression devices ranged from 0% in Louisiana to 100% in several states. Wide geographic disparities in coverage were also observed for the other treatment approaches.

The researchers considered the full array of conservative and surgical approaches to be important in care of patients with lymphedema. “However, less than 12% of individuals who have health insurance, and even fewer patients without health insurance, have access to pneumatic compression and surgical treatments for lymphedema,” they wrote.

Reference

Lynn JV, Hespe GE, Akhter MF, David CM, Kung TA, Myers PL. Cross-sectional analysis of insurance coverage for lymphedema treatments in the United States. JAMA Surg. 2023;158(9):920-926. doi:10.1001/jamasurg.2023.2017