Creating a Policy for Coverage of Lymphatic Surgery: Addressing a Critical Unmet Need

Abstract

Summary:This article describes the key stakeholders and process involved in developing an insurance policy in the United States to establish medical necessity criteria for lymphatic surgery procedures. Lymphedema is a chronic health issue that impacts over 1.2 million patients and is associated with lifelong health, economic, and psychosocial costs. Patients affected have been described as “medical nomads,” as they often interface with multiple providers before receiving an accurate diagnosis and treatment. This underscores the lack of attention and understanding about this disease across all sectors of the medical system. Unlike nations including Sweden and the United Kingdom, which provide insurance coverage for treatment, the United States has lagged behind. As a country, we have neglected to fully recognize the consequences of inadequate treatment of lymphedema, including chronic morbidities such as loss of mobility, psychosocial sequelae, recurrent infections, and even death. Recently, the authors’ lymphatic center had the unique opportunity to help develop a policy that merged their clinical experience, recently established lymphatic care center of excellence criteria, and third-party payer policy expertise. This experience spanned 1 year from June of 2018 to June of 2019. The authors identify how key partnerships helped fill evidentiary gaps that ultimately resulted in policy change.