Lymphedema Treatment: Denial or Insufficient Coverage Reporting Form

The information you provide will assist the Lymphedema Advocacy Group in making future improvements to insurance coverage for lymphedema treatment supplies and services. Please report any instances of denials or insufficient coverage, especially those related to compression garments, bandaging supplies, and pneumatic compression pumps. Responses will be kept confidential.

PLEASE NOTE: Documentation such as denial letters, an Explanation of Benefits statement (EOB), or any written confirmation about your policy’s lack of coverage or reason for denying the coverage is extremely helpful for us to see. At the end of this form, you will have the option to upload a copy or photo of these documents. You cannot save your progress, so please have any such items on hand before you begin, and if desired, black out or cover any personal identifying information.

To learn more about our group or to contact us, please visit our website.

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1. Information Disclosure Agreement
The information you provide will assist the Lymphedema Advocacy Group in making future improvements to insurance coverage for lymphedema treatment supplies and services.

Our group works to enact policy changes that improve coverage for all patients. We do not assist with individual patient appeals and will not share your personal information. (Required.)

I understand and am voluntarily providing this information.

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2. Your Name (Required.)

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3. Your Email (in case we have any follow-up questions) (Required.)

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4. Who are you completing this form for? (Required.)

I am a patient completing it for myself

I am a family member completing it for a patient

I am a healthcare provider filling it out on behalf of a patient

I am a DMEPOS supplier filling it out on behalf of a patient

Other (please specify)

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5. What is the cause of the patient's lymphedema?
We are asking because some states have congenital anomaly laws (primary lymphedema is a congenital anomaly) and because the Women's Health and Cancer Rights Act provides certain guarantees of coverage to women with breast cancer-related lymphedema. (Required.)

Breast Cancer-related Lymphedema (female only)

Primary Lymphedema

Unknown

Other (please specify)

Lymphedema Treatment: Denial or Insufficient Coverage Reporting Form

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2. Your Name (Required.)

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3. Your Email (in case we have any follow-up questions) (Required.)

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4. Who are you completing this form for? (Required.)

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6. If you know the patient’s diagnosis code, please select it from the options below.

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7. State in which the patient's insurance policy is based. (Required.)

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8. What type of insurance does the patient have?
Select your primary insurance type, if you have more than one policy. (Required.)

Lymphedema Treatment: Denial or Insufficient Coverage Reporting Form

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* 2. Your Name (Required.)

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* 3. Your Email (in case we have any follow-up questions) (Required.)

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* 4. Who are you completing this form for? (Required.)

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* 6. If you know the patient’s diagnosis code, please select it from the options below.

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* 7. State in which the patient's insurance policy is based. (Required.)

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* 8. What type of insurance does the patient have? Select your primary insurance type, if you have more than one policy. (Required.)

2. Your Name (Required.)

3. Your Email (in case we have any follow-up questions) (Required.)

4. Who are you completing this form for? (Required.)

6. If you know the patient’s diagnosis code, please select it from the options below.

7. State in which the patient's insurance policy is based. (Required.)

8. What type of insurance does the patient have?
Select your primary insurance type, if you have more than one policy. (Required.)