Aetna Lymphedema Treatments coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Complex decongestive physiotherapy (CDP) — also called complete decongestive therapy or manual lymphoid drainage — is medically necessary when BOTH of the following are met: (A) member has ANY ONE of: evidence of ulceration due to lymphedema; OR intractable lymphedema of the extremities unrelieved by elevation; OR one or more previous admissions to treat complications of intractable lymphedema (i.e., cellulitis, ulceration); AND (B) member has shown a past record of compliance and the member or his/her caregiver is capable of following the instructions associated with CDP.
• Pneumatic compression device WITHOUT calibrated gradient pressure (non-segmented/unicompartmental, or segmented/multicompartmental without manual control of pressure in each chamber) for home use is medically necessary for chronic and severe lymphedema when ALL of the following are met: (1) member has a diagnosis of lymphedema; AND (2) persistence of chronic and severe lymphedema documented by AT LEAST ONE of: marked hyperkeratosis with hyperplasia and hyperpigmentation; OR papillomatosis cutis lymphostatica; OR deformity of elephantiasis; OR skin breakdown with persisting lymphorrhea; OR detailed measurements over time confirming persistence of the lymphedema with a history evidencing a likely etiology; AND (3) the lymphedema is documented to be unresponsive to other clinical treatment over a required four-week trial of conservative therapy (see separate trial-content and re-assessment criteria).
• Required four-week conservative therapy trial for a pneumatic compression device WITHOUT calibrated gradient pressure must include ALL of: (1) regular and compliant use of an appropriate compression bandage system or compression garment providing adequate graduated compression (adequate = sufficient pressure at the lowest pressure point to cause fluid movement and sufficient pressure across the gradient from highest to lowest pressure point to move fluid distal to proximal; must NOT create a tourniquet effect at any point); AND (2) regular exercise; AND (3) elevation of the limb. (Note: when available, manual lymphatic drainage is a key component of conservative treatment, as is appropriate medication treatment when there is concurrent congestive failure.)
• Re-assessment / trial-outcome criteria for a pneumatic compression device WITHOUT calibrated gradient pressure: at the end of the 4-week trial, if there has been improvement the device is NOT medically necessary; where improvement has occurred, conservative therapy must be continued with subsequent reassessment at intervals at least 1 week apart; ONLY when no significant improvement has occurred in the most recent 4 weeks AND the medical necessity criteria are still met may the lymphedema be considered unresponsive to conservative therapy and the device considered medically necessary.
• Pneumatic compression device WITH calibrated gradient pressure (segmented, with manual control of pressure in each chamber) for home use is medically necessary for lymphedema extending onto the chest, trunk and/or abdomen when ALL of the following are met: (1) member has the diagnosis of lymphedema; AND (2) member meets the medical necessity criteria for a pneumatic compression device (without calibrated gradient) as described above; AND (3) member has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest/trunk/abdominal lymphedema has failed to improve with a required four-week trial demonstrating failed response to a pneumatic compression device WITHOUT calibrated gradient pressure.
• Required four-week trial preceding a pneumatic compression device WITH calibrated gradient pressure must include ALL of: (1) at least 4 weeks of regular, daily, multiple-hour home usage of a pneumatic compression device without calibrated gradient pressure after careful in-person fitting, training and supervision by a technician skilled in and who regularly and successfully uses the appliance; AND (2) compliant use of an appropriate compression bandage system or compression garment providing adequate graduated compression (adequate = sufficient pressure at lowest point to cause fluid movement and across the gradient to move fluid distal to proximal; no tourniquet effect; garment prefabricated or custom but must provide adequate graduated compression starting with a minimum of 30 mmHg distally); AND (3) regular exercise; AND (4) elevation where appropriate; AND (5) manual lymphatic drainage (where available) and self-MLD for at least 30 minutes per day; AND (6) evaluation of diet and implementation of any necessary change; AND (7) medications as appropriate (e.g., diuretics and/or other treatment of congestive failure); AND (8) correction (where possible) of anemia and/or hypo-proteinemia.
• Re-assessment / trial-outcome criteria for a pneumatic compression device WITH calibrated gradient pressure: at the end of the 4-week trial, if there has been improvement of the lymphedema extending onto the chest, trunk and/or abdomen, the device is NOT medically necessary; where improvement has occurred, conservative therapy must be continued with subsequent reassessment at intervals at least 1 week apart; when and ONLY when no significant improvement has occurred in the most recent 4 weeks AND the medical necessity criteria are still met is the calibrated gradient pressure device medically necessary.
• A 2-phase lymph preparation and drainage therapy device (e.g., Flexitouch Device, Tactile Systems Technology; Lympha Press Optimal, Lympha Press USA) is considered equally effective to standard segmented pneumatic compression devices WITH calibrated gradient pressure (and thus covered under those criteria).
• The ACTitouch Adaptive Compression Therapy System is considered equally effective to standard segmented pneumatic compression devices WITHOUT calibrated gradient pressure (and thus covered under those criteria).
• Static compression sleeves (e.g., the ReidSleeve, ArmAssist) are medically necessary supplies for members with intractable lymphedema of the arms.
• Static compression sleeves — quantity limits: initial purchase of 3 static compression sleeves and/or gloves per affected arm is medically necessary; replacement of no more than 2 per affected arm every 6 months is medically necessary. Sleeves and gloves are separate items: if both are required, three gloves AND three sleeves per affected arm are medically necessary initially, with two additional of each in subsequent 6-month intervals, if needed.
• Excisional procedures (debulking; liposuction including suction-assisted protein lipectomy (SAPL), also known as suction lipectomy) are medically necessary for the treatment of chronic refractory lymphedema.
• Federal-law mandate (HR 4328, Public Law 105-277): individual and employer group health plans (indemnity, PPO, POS, HMO) that provide medical and surgical benefits with respect to a mastectomy must cover lymphedema treatment, determined in consultation with the attending physician and the member, for a participant/beneficiary receiving mastectomy benefits who elects breast reconstruction after the mastectomy; therapy is subject to annual deductibles and co-insurance provisions for physical therapy but is NOT subject to visit-limitation provisions for physical therapy.
• Benefit-limited coverage carve-out (lymphedema pumps): for members WITHOUT DME benefits, lymphedema pumps are only covered for members with arm lymphedema due to mastectomy for breast cancer who meet the criteria for a lymphedema pump stated above.
• Benefit-limited coverage carve-out (static compression sleeves): for members whose plans exclude coverage of supplies, static compression sleeves are only covered for intractable lymphedema of the arms due to mastectomy for breast cancer.
• Lymphedema pumps can be initiated in the clinic or in the home setting; although the literature suggests use is commonly initiated in the hospital, there is no medical necessity for hospital initiation unless the member has other complications of lymphedema (i.e., cellulitis) that would require hospitalization.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 97140·PA verdict·Rate
• E0650·PA verdict·Rate
• E0651·PA verdict·Rate
• E0652·PA verdict·Rate
• E0655·PA verdict·Rate
• E0656·PA verdict·Rate
• E0657·PA verdict·Rate
• E0660·PA verdict·Rate
• E0665·PA verdict·Rate
• E0666·PA verdict·Rate
• E0667·PA verdict·Rate
• E0668·PA verdict·Rate
• E0669·PA verdict·Rate
• E0670·PA verdict·Rate
• E0671·PA verdict·Rate
• E0672·PA verdict·Rate
• E0673·PA verdict·Rate
• A6520·PA verdict·Rate
• A6530·PA verdict·Rate
• A6549·PA verdict·Rate
• S8950·PA verdict·Rate

Documentation required

• There must be sufficient medical information included in the medical record to demonstrate that all applicable coverage criteria are met.
• A new prescription from the treating practitioner is required each time a new device or repair is requisitioned. (Treating practitioner = physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is NOT a treating practitioner.)
• Supplier-prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician. There must be information in the member's medical record that supports medical necessity and substantiates any supplier-prepared statement or treating practitioner's attestation. Forms are subject to corroboration with information in the medical record.
• Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary.
• A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills for an item without first receiving a completed SWO, the claim will be denied as not medically necessary.
• The SWO must contain ALL of the following: member's name or identification number; order date; general description of the item (a HCPCS code, HCPCS code narrative, or brand name/model number, plus all concurrently ordered options/accessories/features or supplies that are separately billed or require an upgraded code, listed separately); each item or service listed individually with HCPCS code and quantity to be dispensed; treating practitioner name and NPI; treating practitioner's signature.
• For a pneumatic compression device trial: re-assessments must, at a minimum, include detailed measurements obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate.

Frequently asked questions

When does Aetna cover Lymphedema Treatments (CPT 97140), and what gets it denied?

Aetna CPB 0069 covers lymphedema treatments: complex decongestive physiotherapy, pneumatic compression pumps (with and without calibrated gradient pressure), static compression sleeves, and excisional debulking/liposuction for chronic refractory disease. The central gate for pump coverage is documented chronic/severe lymphedema that remains unresponsive after a required four-week trial of conservative therapy (compression, exercise, elevation), with calibrated-gradient pumps reserved for chest/trunk/abdomen lymphedema that fails a non-calibrated pump trial; numerous surgical, device, and therapy approaches are considered experimental/investigational. The bulletin is silent on prior authorization. Coverage criteria include: Complex decongestive physiotherapy (CDP) — also called complete decongestive therapy or manual lymphoid drainage — is medically necessary when BOTH of the following are met: (A) member has ANY ONE of: evidence of ulceration due to lymphedema; OR intractable lymphedema of the extremities unrelieved by elevation; OR one or more previous admissions to treat complications of intractable lymphedema (i.e., cellulitis, ulceration); AND (B) member has shown a past record of compliance and the member or his/her caregiver is capable of following the instructions associated with CDP.; Pneumatic compression device WITHOUT calibrated gradient pressure (non-segmented/unicompartmental, or segmented/multicompartmental without manual control of pressure in each chamber) for home use is medically necessary for chronic and severe lymphedema when ALL of the following are met: (1) member has a diagnosis of lymphedema; AND (2) persistence of chronic and severe lymphedema documented by AT LEAST ONE of: marked hyperkeratosis with hyperplasia and hyperpigmentation; OR papillomatosis cutis lymphostatica; OR deformity of elephantiasis; OR skin breakdown with persisting lymphorrhea; OR detailed measurements over time confirming persistence of the lymphedema with a history evidencing a likely etiology; AND (3) the lymphedema is documented to be unresponsive to other clinical treatment over a required four-week trial of conservative therapy (see separate trial-content and re-assessment criteria).; Required four-week conservative therapy trial for a pneumatic compression device WITHOUT calibrated gradient pressure must include ALL of: (1) regular and compliant use of an appropriate compression bandage system or compression garment providing adequate graduated compression (adequate = sufficient pressure at the lowest pressure point to cause fluid movement and sufficient pressure across the gradient from highest to lowest pressure point to move fluid distal to proximal; must NOT create a tourniquet effect at any point); AND (2) regular exercise; AND (3) elevation of the limb. (Note: when available, manual lymphatic drainage is a key component of conservative treatment, as is appropriate medication treatment when there is concurrent congestive failure.); Re-assessment / trial-outcome criteria for a pneumatic compression device WITHOUT calibrated gradient pressure: at the end of the 4-week trial, if there has been improvement the device is NOT medically necessary; where improvement has occurred, conservative therapy must be continued with subsequent reassessment at intervals at least 1 week apart; ONLY when no significant improvement has occurred in the most recent 4 weeks AND the medical necessity criteria are still met may the lymphedema be considered unresponsive to conservative therapy and the device considered medically necessary.; Pneumatic compression device WITH calibrated gradient pressure (segmented, with manual control of pressure in each chamber) for home use is medically necessary for lymphedema extending onto the chest, trunk and/or abdomen when ALL of the following are met: (1) member has the diagnosis of lymphedema; AND (2) member meets the medical necessity criteria for a pneumatic compression device (without calibrated gradient) as described above; AND (3) member has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest/trunk/abdominal lymphedema has failed to improve with a required four-week trial demonstrating failed response to a pneumatic compression device WITHOUT calibrated gradient pressure.; Required four-week trial preceding a pneumatic compression device WITH calibrated gradient pressure must include ALL of: (1) at least 4 weeks of regular, daily, multiple-hour home usage of a pneumatic compression device without calibrated gradient pressure after careful in-person fitting, training and supervision by a technician skilled in and who regularly and successfully uses the appliance; AND (2) compliant use of an appropriate compression bandage system or compression garment providing adequate graduated compression (adequate = sufficient pressure at lowest point to cause fluid movement and across the gradient to move fluid distal to proximal; no tourniquet effect; garment prefabricated or custom but must provide adequate graduated compression starting with a minimum of 30 mmHg distally); AND (3) regular exercise; AND (4) elevation where appropriate; AND (5) manual lymphatic drainage (where available) and self-MLD for at least 30 minutes per day; AND (6) evaluation of diet and implementation of any necessary change; AND (7) medications as appropriate (e.g., diuretics and/or other treatment of congestive failure); AND (8) correction (where possible) of anemia and/or hypo-proteinemia.; Re-assessment / trial-outcome criteria for a pneumatic compression device WITH calibrated gradient pressure: at the end of the 4-week trial, if there has been improvement of the lymphedema extending onto the chest, trunk and/or abdomen, the device is NOT medically necessary; where improvement has occurred, conservative therapy must be continued with subsequent reassessment at intervals at least 1 week apart; when and ONLY when no significant improvement has occurred in the most recent 4 weeks AND the medical necessity criteria are still met is the calibrated gradient pressure device medically necessary.; A 2-phase lymph preparation and drainage therapy device (e.g., Flexitouch Device, Tactile Systems Technology; Lympha Press Optimal, Lympha Press USA) is considered equally effective to standard segmented pneumatic compression devices WITH calibrated gradient pressure (and thus covered under those criteria).; The ACTitouch Adaptive Compression Therapy System is considered equally effective to standard segmented pneumatic compression devices WITHOUT calibrated gradient pressure (and thus covered under those criteria).; Static compression sleeves (e.g., the ReidSleeve, ArmAssist) are medically necessary supplies for members with intractable lymphedema of the arms.; Static compression sleeves — quantity limits: initial purchase of 3 static compression sleeves and/or gloves per affected arm is medically necessary; replacement of no more than 2 per affected arm every 6 months is medically necessary. Sleeves and gloves are separate items: if both are required, three gloves AND three sleeves per affected arm are medically necessary initially, with two additional of each in subsequent 6-month intervals, if needed.; Excisional procedures (debulking; liposuction including suction-assisted protein lipectomy (SAPL), also known as suction lipectomy) are medically necessary for the treatment of chronic refractory lymphedema.; Federal-law mandate (HR 4328, Public Law 105-277): individual and employer group health plans (indemnity, PPO, POS, HMO) that provide medical and surgical benefits with respect to a mastectomy must cover lymphedema treatment, determined in consultation with the attending physician and the member, for a participant/beneficiary receiving mastectomy benefits who elects breast reconstruction after the mastectomy; therapy is subject to annual deductibles and co-insurance provisions for physical therapy but is NOT subject to visit-limitation provisions for physical therapy.; Benefit-limited coverage carve-out (lymphedema pumps): for members WITHOUT DME benefits, lymphedema pumps are only covered for members with arm lymphedema due to mastectomy for breast cancer who meet the criteria for a lymphedema pump stated above.; Benefit-limited coverage carve-out (static compression sleeves): for members whose plans exclude coverage of supplies, static compression sleeves are only covered for intractable lymphedema of the arms due to mastectomy for breast cancer.; Lymphedema pumps can be initiated in the clinic or in the home setting; although the literature suggests use is commonly initiated in the hospital, there is no medical necessity for hospital initiation unless the member has other complications of lymphedema (i.e., cellulitis) that would require hospitalization.. Applies to 21 codes: 97140, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, A6520, A6530, A6549, S8950. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: There must be sufficient medical information included in the medical record to demonstrate that all applicable coverage criteria are met.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned. (Treating practitioner = physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is NOT a treating practitioner.); Supplier-prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician. There must be information in the member's medical record that supports medical necessity and substantiates any supplier-prepared statement or treating practitioner's attestation. Forms are subject to corroboration with information in the medical record.; Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary.; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills for an item without first receiving a completed SWO, the claim will be denied as not medically necessary.; The SWO must contain ALL of the following: member's name or identification number; order date; general description of the item (a HCPCS code, HCPCS code narrative, or brand name/model number, plus all concurrently ordered options/accessories/features or supplies that are separately billed or require an upgraded code, listed separately); each item or service listed individually with HCPCS code and quantity to be dispensed; treating practitioner name and NPI; treating practitioner's signature.; For a pneumatic compression device trial: re-assessments must, at a minimum, include detailed measurements obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate. Policy exclusions and limitations: A pneumatic compression device WITHOUT calibrated gradient pressure is NOT medically necessary if, at the end of the 4-week conservative therapy trial, there has been improvement.; A pneumatic compression device WITH calibrated gradient pressure is NOT medically necessary if, at the end of the 4-week trial, there has been improvement of the lymphedema extending onto the chest, trunk and/or abdomen.; Experimental/investigational/unproven: Acoustic radiation force impulse elastography for measurement of tissue stiffness in limb lymphedema.; Experimental/investigational/unproven: Acupuncture for the treatment of breast cancer-related lymphedema.; Experimental/investigational/unproven: Advanced pneumatic compression (e.g., the Flexitouch device) for the treatment of head and neck edema.; Experimental/investigational/unproven: Aquatic therapy / aqua lymphatic therapy for the treatment of lymphedema.; Experimental/investigational/unproven: Bioelectrical impedance analysis for evaluation of limb lymphedema.; Experimental/investigational/unproven: Bio-impedance devices (e.g., L-Dex U400) for the diagnosis or management of lymphedema.; Experimental/investigational/unproven: Bio-impedance spectroscopy-triggered compression for chronic breast cancer lymphedema prevention.; Experimental/investigational/unproven: Combined adipose-derived stem cell and vascularized lymph node transfer for treatment of secondary lymphedema.; Experimental/investigational/unproven: Combined intermittent pneumatic compression and complete decongestive therapy for the treatment of breast cancer-related upper limb lymphedema.; Experimental/investigational/unproven: Compression bras for post-mastectomy lymphedema.; Experimental/investigational/unproven: Compression garments for lymphedema of the genitals, head, and neck.; Experimental/investigational/unproven: Extracorporeal shockwave therapy for the treatment of breast cancer-related lymphedema (BCRL).; Experimental/investigational/unproven: Fibro-lipo-lympho-aspiration (FLLA) for the treatment of lymphedema.; Experimental/investigational/unproven: Genetic testing for predisposition to lymphedema following breast cancer therapy.; Experimental/investigational/unproven: Immediate lymphatic reconstruction for the prevention of BCRL.; Experimental/investigational/unproven: Kinesio taping for the treatment of breast cancer-related lymphedema.; Experimental/investigational/unproven: Koya Dayspring System for the promotion of wound healing, and treatment of lymphedema and venous insufficiency.; Experimental/investigational/unproven: Low-level light therapy (also known as low-level laser therapy and photo-bio-modulation therapy) for the treatment of lymphedema.; Experimental/investigational/unproven: Lymph node transfer (also known as vascularized lymph node transfer) for the treatment of lymphedema due to cervical cancer or melanoma, and post-mastectomy lymphedema.; Experimental/investigational/unproven: Magnetic resonance imaging for evaluation of therapeutic response in BCRL.; Experimental/investigational/unproven: Matrix rhythm therapy for the treatment of lymphedema.; Experimental/investigational/unproven: Maya abdominal therapy for manual lymphatic drainage.; Experimental/investigational/unproven: Microsurgical treatments (microsurgical lymphatico-venous anastomosis, lymphatic-capsular-venous anastomosis, lymphovenous bypass) for the treatment of members with chronic obstructive lymphedema.; Experimental/investigational/unproven: Minimally invasive tissue excision with possible redundant skin excision (the MITESE procedure) for the treatment of chronic lymphedema.; Experimental/investigational/unproven: Nanofibrillar collagen scaffolds and silicone tubes for the treatment of lymphedema.; Experimental/investigational/unproven: Omental lymph node transfer for the treatment of lymphedema.; Experimental/investigational/unproven: Platelet-rich plasma for the treatment of lymphedema.; Experimental/investigational/unproven: Pneumatic compression devices with calibrated gradient pressure used to treat lymphedema NOT extending onto the chest, trunk and/or abdomen.; Experimental/investigational/unproven: Reverse lymphatic mapping.; Experimental/investigational/unproven: Tissue transfers (e.g., omental flap) for the treatment of lymphedema.; Experimental/investigational/unproven: Whole body vibration for the treatment of lymphedema. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Lymphedema Treatments?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: There must be sufficient medical information included in the medical record to demonstrate that all applicable coverage criteria are met.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned. (Treating practitioner = physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is NOT a treating practitioner.); Supplier-prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician. There must be information in the member's medical record that supports medical necessity and substantiates any supplier-prepared statement or treating practitioner's attestation. Forms are subject to corroboration with information in the medical record.; Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary.; A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; if the supplier bills for an item without first receiving a completed SWO, the claim will be denied as not medically necessary.; The SWO must contain ALL of the following: member's name or identification number; order date; general description of the item (a HCPCS code, HCPCS code narrative, or brand name/model number, plus all concurrently ordered options/accessories/features or supplies that are separately billed or require an upgraded code, listed separately); each item or service listed individually with HCPCS code and quantity to be dispensed; treating practitioner name and NPI; treating practitioner's signature.; For a pneumatic compression device trial: re-assessments must, at a minimum, include detailed measurements obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate.

What does Aetna exclude for Lymphedema Treatments?

Policy exclusions and limitations: A pneumatic compression device WITHOUT calibrated gradient pressure is NOT medically necessary if, at the end of the 4-week conservative therapy trial, there has been improvement.; A pneumatic compression device WITH calibrated gradient pressure is NOT medically necessary if, at the end of the 4-week trial, there has been improvement of the lymphedema extending onto the chest, trunk and/or abdomen.; Experimental/investigational/unproven: Acoustic radiation force impulse elastography for measurement of tissue stiffness in limb lymphedema.; Experimental/investigational/unproven: Acupuncture for the treatment of breast cancer-related lymphedema.; Experimental/investigational/unproven: Advanced pneumatic compression (e.g., the Flexitouch device) for the treatment of head and neck edema.; Experimental/investigational/unproven: Aquatic therapy / aqua lymphatic therapy for the treatment of lymphedema.; Experimental/investigational/unproven: Bioelectrical impedance analysis for evaluation of limb lymphedema.; Experimental/investigational/unproven: Bio-impedance devices (e.g., L-Dex U400) for the diagnosis or management of lymphedema.; Experimental/investigational/unproven: Bio-impedance spectroscopy-triggered compression for chronic breast cancer lymphedema prevention.; Experimental/investigational/unproven: Combined adipose-derived stem cell and vascularized lymph node transfer for treatment of secondary lymphedema.; Experimental/investigational/unproven: Combined intermittent pneumatic compression and complete decongestive therapy for the treatment of breast cancer-related upper limb lymphedema.; Experimental/investigational/unproven: Compression bras for post-mastectomy lymphedema.; Experimental/investigational/unproven: Compression garments for lymphedema of the genitals, head, and neck.; Experimental/investigational/unproven: Extracorporeal shockwave therapy for the treatment of breast cancer-related lymphedema (BCRL).; Experimental/investigational/unproven: Fibro-lipo-lympho-aspiration (FLLA) for the treatment of lymphedema.; Experimental/investigational/unproven: Genetic testing for predisposition to lymphedema following breast cancer therapy.; Experimental/investigational/unproven: Immediate lymphatic reconstruction for the prevention of BCRL.; Experimental/investigational/unproven: Kinesio taping for the treatment of breast cancer-related lymphedema.; Experimental/investigational/unproven: Koya Dayspring System for the promotion of wound healing, and treatment of lymphedema and venous insufficiency.; Experimental/investigational/unproven: Low-level light therapy (also known as low-level laser therapy and photo-bio-modulation therapy) for the treatment of lymphedema.; Experimental/investigational/unproven: Lymph node transfer (also known as vascularized lymph node transfer) for the treatment of lymphedema due to cervical cancer or melanoma, and post-mastectomy lymphedema.; Experimental/investigational/unproven: Magnetic resonance imaging for evaluation of therapeutic response in BCRL.; Experimental/investigational/unproven: Matrix rhythm therapy for the treatment of lymphedema.; Experimental/investigational/unproven: Maya abdominal therapy for manual lymphatic drainage.; Experimental/investigational/unproven: Microsurgical treatments (microsurgical lymphatico-venous anastomosis, lymphatic-capsular-venous anastomosis, lymphovenous bypass) for the treatment of members with chronic obstructive lymphedema.; Experimental/investigational/unproven: Minimally invasive tissue excision with possible redundant skin excision (the MITESE procedure) for the treatment of chronic lymphedema.; Experimental/investigational/unproven: Nanofibrillar collagen scaffolds and silicone tubes for the treatment of lymphedema.; Experimental/investigational/unproven: Omental lymph node transfer for the treatment of lymphedema.; Experimental/investigational/unproven: Platelet-rich plasma for the treatment of lymphedema.; Experimental/investigational/unproven: Pneumatic compression devices with calibrated gradient pressure used to treat lymphedema NOT extending onto the chest, trunk and/or abdomen.; Experimental/investigational/unproven: Reverse lymphatic mapping.; Experimental/investigational/unproven: Tissue transfers (e.g., omental flap) for the treatment of lymphedema.; Experimental/investigational/unproven: Whole body vibration for the treatment of lymphedema. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT