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.

I understand and am voluntarily providing this information.

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* 2. Your Name

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

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* 4. Who are you completing this form for?

I am a patient or 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.

Breast Cancer-related Lymphedema (female only)

Primary Lymphedema

Unknown

Other (please specify)

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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.

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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.

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* 9. If the patient's primary insurance is a Medicare Advantage or Private plan, what company administers it?
For example, United Health Care, Aetna, etc.

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* 10. If the patient has a secondary insurance or supplemental plan please list that here, and note whether the coverage issue is with the secondary or primary insurance provider.

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* 11. What lymphedema treatment supply or service is the patient being denied coverage for or receiving insufficient coverage for?

Compression bandages

Compression garments

Compression wraps with adjustable straps

Nighttime compression

Compression accessories (i.e., donning & doffing, zipper)

Compression pump

Complete decongestive therapy/manual lymphatic drainage

None of the above. Please clarify in comments.

Please describe the exact item or item for each selected category.

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* 12. What was the date of service or approximate date the issue was initiated?
If you don't know the specific day just enter 01 in the date field, e.g 10/01/2024 for October 2024.

Date of Service

Date

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* 13. Has an appeal been filed?
If not, we strongly encourage appealing, as many patients win on appeal, and this documentation of the denial can help with future policy changes.

Yes

No, but I plan to

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* 14. What was the reason given for the denial or lack of coverage?
Please provide as many details as you feel comfortable sharing.

Not medically necessary

Non-covered benefit

Submission/clerical error

Insufficient clinical documentation

Duplicate billing

Other (please specify)

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* 15. Was a claim filed and benefits information provided directly from the insurance company, or was the information only communicated to the patient by a Durable Medical Equipment (DME) supplier?

benefits information provided directly from the insurance company

information provided by DME supplier

Comments

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* 16. Were there any reasons why a DME supplier was not able or was not willing to bill your insurance?
Please provide as many details as you feel comfortable sharing.

lack of an in-network DME supplier

lack of a specific HCPCS/billing code for an item

an unspecified reimbursement rate for an item

unable to find a DME supplier who sells the item or items you have been prescribed

problems with documentation, such as insufficient details on the prescription and/or in the clinical notes

other, please specify in Comments

Comments

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* 17. If the issue involves a compression garment or a compression pump, what is the name of the supplier the product was ordered from, or attempted to order from?

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* 18. If you would like to share any additional information about the lymphedema treatment supply or service that the patient is being denied coverage for, or receiving insufficient coverage for, please do so here.

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* 19. Please attach any 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. This is extremely helpful for us to see. Feel free to redact/ blackout personal information such as name, address, and contact information.

PDF, PNG, JPG, JPEG file types only.

Choose File

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* 20. Additional attachment (if needed)

PDF, PNG, JPG, JPEG file types only.

Choose File

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* 21. Additional attachment (if needed)

PDF, PNG, JPG, JPEG file types only.

Choose File

Lymphedema Treatment: Denial or Insufficient Coverage Reporting Form

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* 2. Your Name

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

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* 4. Who are you completing this form for?

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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.

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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.

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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.

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* 9. If the patient's primary insurance is a Medicare Advantage or Private plan, what company administers it? For example, United Health Care, Aetna, etc.

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* 10. If the patient has a secondary insurance or supplemental plan please list that here, and note whether the coverage issue is with the secondary or primary insurance provider.

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* 11. What lymphedema treatment supply or service is the patient being denied coverage for or receiving insufficient coverage for?

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* 12. What was the date of service or approximate date the issue was initiated?If you don't know the specific day just enter 01 in the date field, e.g 10/01/2024 for October 2024.

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* 13. Has an appeal been filed? If not, we strongly encourage appealing, as many patients win on appeal, and this documentation of the denial can help with future policy changes.

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* 14. What was the reason given for the denial or lack of coverage? Please provide as many details as you feel comfortable sharing.

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* 15. Was a claim filed and benefits information provided directly from the insurance company, or was the information only communicated to the patient by a Durable Medical Equipment (DME) supplier?

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* 16. Were there any reasons why a DME supplier was not able or was not willing to bill your insurance?Please provide as many details as you feel comfortable sharing.

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* 17. If the issue involves a compression garment or a compression pump, what is the name of the supplier the product was ordered from, or attempted to order from?

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* 18. If you would like to share any additional information about the lymphedema treatment supply or service that the patient is being denied coverage for, or receiving insufficient coverage for, please do so here.

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* 20. Additional attachment (if needed)

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* 21. Additional attachment (if needed)

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

* 9. If the patient's primary insurance is a Medicare Advantage or Private plan, what company administers it?
For example, United Health Care, Aetna, etc.

* 12. What was the date of service or approximate date the issue was initiated?
If you don't know the specific day just enter 01 in the date field, e.g 10/01/2024 for October 2024.

* 13. Has an appeal been filed?
If not, we strongly encourage appealing, as many patients win on appeal, and this documentation of the denial can help with future policy changes.

* 14. What was the reason given for the denial or lack of coverage?
Please provide as many details as you feel comfortable sharing.

* 16. Were there any reasons why a DME supplier was not able or was not willing to bill your insurance?
Please provide as many details as you feel comfortable sharing.