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. Question Title * 1. Information Disclosure AgreementThe 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. Question Title * 2. Your Name Question Title * 3. Your Email (in case we have any follow-up questions) Email address Question Title * 4. Who are you completing this form for? 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) Question Title * 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) Question Title * 6. If you know the patient’s diagnosis code, please select it from the options below. Q82.0 Hereditary Lymphedema (also referred to as Primary) I89.0 Lymphedema, not elsewhere classified (also referred to as Secondary) I97.2 Postmastectomy Lymphedema I97.89 Other postprocedural complications and disorders of the circulatory system, not elsewhere classified Other (please specify) Question Title * 7. State in which the patient's insurance policy is based. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Question Title * 8. What type of insurance does the patient have? Select your primary insurance type, if you have more than one policy. Traditional Medicare (fee-for-service) Medicare Advantage Traditional Medicaid (fee-for-service) Medicaid Managed Care CHIP TriCare VA Healthcare Private (ACA health exchange plan) Private (self-funded plan) Private (all other plans) Question Title * 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. Question Title * 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. Question Title * 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. Question Title * 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 Question Title * 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 No Question Title * 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) Question Title * 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 Question Title * 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 Question Title * 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? Question Title * 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. Question Title * 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 No file chosen Remove File 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. Question Title * 20. Additional attachment (if needed) PDF, PNG, JPG, JPEG file types only. Choose File No file chosen Remove File Additional attachment (if needed) Question Title * 21. Additional attachment (if needed) PDF, PNG, JPG, JPEG file types only. Choose File No file chosen Remove File Additional attachment (if needed) Send me a copy of my responses via email Done