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Complete Decongestive Therapy (CDT)
MA07.042

Policy

Complete decongestive therapy (CDT) is considered medically necessary and, therefore, covered when all of the following medical necessity criteria are met:
  • The individual has a diagnosis of lymphedema.
  • The individual is symptomatic (e.g., numbness, tightness, stiffness, heaviness, and limb swelling) for lymphedema with functional limitation (e.g., difficulty dressing, decreased walking endurance, difficulty swallowing, difficulty speaking, compromised airway).
  • The individual or caregiver is able to comprehend, comply, and continue the treatment regimen independently in the home setting.
  • The services will be performed by an eligible healthcare provider who has received specialized training in this form of treatment.
The repetitive performance of CDT services to prevent regression or the point at which the individual is unlikely to attain further functional ability from additional therapy are​ considered maintenance. Maintenance therapy is not covered by the Company because it is an item or service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. When an individual is receiving CDT, the initial and subsequent medical record documentation must include the following components:
  • Documentation of the diagnosis of lymphedema, including the individual's symptoms, the cause of lymphedema, and whether there has been any prior treatment.
  • Initial measurements (e.g., measurements of affected and unaffected regions of the body), or landmark measurements (e.g., chin to top of head or neck on a face diagram) or other confirmation of lymphedema (e.g., serial photographs, especially when measurements cannot be obtained.
  • Subsequent measurements (e.g., measurements of affected and unaffected areas of the body) or other confirmation (e.g., serial photographs) of lymphedema and progress reports showing a reduction in size.
  • Progress reports addressing the expected outcome, as well as the expected duration of treatment.
  • A response from the individual or the individual's caregiver confirming their understanding of the education and ability to take on responsibilities for the treatment: the ongoing progress reports must document the individual's or the caregiver's response to, and understanding of, the education and the ability to continue the treatment regimen in the home setting.

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, complete decongestive therapy (CDT) services are covered under the medical benefits of the Company’s Medicare Advantage products when medical necessity criteria in the medical policy are met.

Benefits for all services related to outpatient physical therapy (PT)/occupational therapy (OT) are provided to members in accordance with the Evidence of Coverage.

Description

The lymphatic system has two primary immunologic functions: activating the inflammatory response and controlling infections. In addition, the lymphatic system drains protein-containing fluid from body tissue and conducts it in a unidirectional flow to the circulatory system. Interruption in this drainage system results in the swelling of a body part, usually an extremity. This is referred to as lymphedema, an abnormal accumulation of lymphatic fluid.

There are two types of lymphedema: primary and secondary. Primary lymphedema is an inherited malformation of the lymph vessels and/or lymph node development. It is less common than secondary lymphedema and may be caused by conditions such as Milroy disease or congenital deformities. Secondary lymphedema is acquired and occurs from damage to the lymphatic network. Damage to formerly functioning lymphatic channels may be caused by infection, physical trauma, the surgical removal of regional lymph nodes, post-irradiation, or can be a result of lymph node obstruction due to malignancy. Lymphedema following breast cancer has been primarily studied; however, lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer, and sarcoma. As a result, lymphedema can occur in regions of the body that include the upper and lower extremities, genitalia, neck, and trunk. Occasionally, chronic swelling and lymph displacement will cause the skin to develop an open wound. The use of compression bandaging on such wounds can assist with healing as it promotes venous circulation and helps improve the reabsorption of fluid in the tissue spaces.

Currently, there is no cure for lymphedema. Treatment consists of a multimodality regimen called complete decongestive therapy (CDT), sometimes referred to by other terms, which include, but are not limited to, complex decongestive therapy, combined decongestive therapy, complex decongestive physiotherapy, and decongestive lymphatic therapy. When administered properly, CDT assists in the removal of lymph drainage from congested areas and decreases swelling; enhances the individual's functional status (e.g., activities of daily living, mobility); reduces skin fibrosis and improves skin condition; relieves discomfort; and reduces the risk of cellulitis and Stewart-Treves syndrome, a rare form of angiosarcoma. A CDT program typically consists of the following components:
  • Skin care
  • Manual lymph drainage (MLD)
  • Multilayer, short-stretch compressive bandaging of the affected area
  • Lymphatic exercise
  • Education in lymphedema self-management and the use of compression garments.
CDT consists of two phases: the initial reductive phase (Phase I) followed by a maintenance phase (Phase II). In Phase I, the main goals are reducing the size and improving the condition of the skin of the affected body part. The site, stage, severity, and complexity of the individual's lymphedema determine the form of management program that will be required. The average duration of the initial reductive phase is 1 to 2 weeks, depending on the condition of the individual and the progress of therapy. During the time of the initial reductive phase, treatment should be evaluated continuously and appropriate alterations made according to the needs of the individual and the effectiveness of the selected regimen. Adequate time must be allowed for education and instruction so the individual or caregiver can independently continue therapy in the home setting. Phase II, the maintenance phase, is the ongoing, individualized self-management phase that ensures the gains of Phase I are maintained in the long term. The self-management program typically includes self-lymph drainage (e.g., simple lymphatic drainage), lymphatic exercises, a skin care regimen, and compression bandages or garments that the individual or caregiver learns to apply. The maximum benefits of CDT are only expected if the individual continues treatment at home.

References

Agency for Healthcare Research and Quality (AHRQ). Technology Assessment: Diagnosis and Treatment of Secondary Lymphedema. [Centers for Medicare and Medicaid Services Web site]. 05/28/2010. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id66aTA.pdf. Accessed July 09, 2024.

American Cancer Society (ACS). Women's Health and Cancer Rights Act. [ACS Web site]. Revised 05/13/2019. Available at: https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/health-insurance-laws/womens-health-and-cancer-rights-act.html. Accessed July 09, 2024.

American Cancer Society. Lymphedema. [American Cancer Society Web site]. Revised 05/25/2021. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/lymphedema.html. Accessed July 09, 2024.

Bohmert J, Moffat M, Zadai C. §6H: Impaired circulation and anthropometric dimensions associated with lymphatic systems disorders. In: American Physical Therapy Association, eds. Guide to Physical Therapy Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001: 569-585.

Bozkurt M, Palmer LJ, Guo Y. Effectiveness of decongestive lymphatic therapy in patients with lymphedema resulting from breast cancer treatment regardless of previous lymphedema treatment. Breast J. 2017;23(2):154-158.

Breastcancer.org. Complete decongestive therapy (CDT). 03/10/2022. [Breastcancer.org Web site]. Available at: https://www.breastcancer.org/treatment/lymphedema/treatments/cdt. Accessed on July 09, 2024.

Dayes IS, Whelan TJ, Julian JA, et al. Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer. J Clin Oncol. 2013;31(30):3758-63.

Do JH, Choi KH, Ahn JS, et al. Effects of a complex rehabilitation program on edema status, physical function, and quality of life in lower-limb lymphedema after gynecological cancer surgery. Gynecol Oncol. 2017;147(2):450-455.

European Wound Management Association (EWMA). Best practice for the management of lymphoedema: International consensus. 2006. [EWMA Web site]. Available at: https://woundsinternational.com/wp-content/uploads/sites/8/2023/02/4335b42108c9c1fd8b4af44f3db4b2c2.pdf. Accessed on July 09, 2024.


Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53(1):3-19.

Ezzo J, Manheimer E, McNeely ML, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015;5:CD003475.

Feely MA, Olsen KD, Gamble GL, et al. Cutaneous lymphatics and chronic lymphedema of the head and neck. Clin Anat. 2012;25:72-85.

Gradalski T, Ochalek K, Kurpiewska J. Complex decongestive lymphatic therapy with or without Vodder II manual lymph drainage in more severe chronic postmastectomy upper limb lymphedema: a randomized noninferiority prospective study. J Pain Symptom Manage. 2015;50(6):750-757.

Hacard F, Machet L, Caille A, et al. Measurement of skin thickness and skin elasticity to evaluate the effectiveness of intensive decongestive treatment in patients with lymphoedema: a prospective study. Skin Res Technol. 2014;20(3):274-281.

Howell D, Ezzo J, Bily L, Johansson K. Complete decongestive therapy for lymphedema following breast cancer treatment (Protocol). Cochrane Database Syst Rev. 2002;1:CD003475.

Huit M. Clinical practice development: lymphoedema in patients treated for head and neck cancer. J Lymphoedema. 2011;6(1):50-57.

Kim do S, Sim YJ, Jeong HJ, et al. Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial. Arch Phys Med Rehabil. 2010;91(12):1844-1848.

International Society of Lymphology (ISL). 2009 consensus document of the International Society of Lymphology: the diagnosis and treatment of peripheral lymphedema. [ISL Web site]. 2009. Available at: http://www.u.arizona.edu/~witte/2009consensus.pdf. July 09, 2024.

Lewin JS, Hutcheson KA, Barringer DA, et al. Preliminary experience with head and neck lymphedema and swallowing function in patients treated for head and neck cancer. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2010;19(2):45-52.


Lurie F, Malgor RD, Carman T, et al. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology. 2020;37(4):252-266. 

Mayrovitz HN. The standard of care for lymphedema: current concepts and physiological considerations. Lymph Res Biol. 2009;7(2):101-108.

McNeely M, Campbell OM, et al. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database Syst Rev. 2010;6:CD005211.

Mehrara B. Breast cancer-associated lymphedema. 04/26/22. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed July 09, 2024.

Mehrara B, Ashinoff RL, Chang EI. Clinical features, diagnosis,and staging peripheral lymphedema. 06/14/2024. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed July 9, 2024.


Mehrara B, Chang EI, Ashinoff RL. Management of peripheral lymphedema. 05/29/2024. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed July 9, 2024.


Melam GR, Buragadda S, Alhusaini AA, et al. Effect of complete decongestive therapy and home program on health- related quality of life in post mastectomy lymphedema patients. BMC Womens Health. 2016;16:23.

Melgaard D. What is the effect of treating secondary lymphedema after breast cancer with complete decongestive physiotherapy when the bandage is replaced with Kinesio Textape? - A pilot study. Physiother Theory Pract. 2016;32(6):446-451.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35036: Therapy and rehabilitation services (PT, OT). [Novitas Solution Web site]. Original: 10/01/15. (Revised:  03/09/2022). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35036&ver=80&Date=&DocID=L35036&bc=iAAAABAAAAAA&. Accessed July 09, 2024.

Oremus M, Dayes I, Walker K, et al. Systematic review: conservative treatment for secondary lymphedema. BMC Cancer. 2012;12:6.

Pekyavaº NÖ, Tunay VB, Akbayrak T, et al. Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study. Eur J Oncol Nurs. 2014;18(6):585-590.

Piso DU, Eckardt A, Liebermann A, et al. Early rehabilitation of head-neck edema after curative surgery for orofacial tumors. Am J Phys Med Rehabil. 2001;80(4):260-269.

Preston NJ, Seers K, Mortimer PS. Physical therapies for reducing and controlling lymphoedema of the limbs (Review). Cochrane Database Syst Rev. 2004;4:CD003141.

Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of the role of adjunctive intermittent pneumatic compression. Cancer. 2002;95:2260-2267.

Tambour M, Tange B, Christensen R, et al. Effect of physical therapy on breast cancer related lymphedema: protocol for a multicenter, randomized, single-blind, equivalence trial. BMC Cancer. 2014;14:239.

United States (US) Department of Labor (DOL). Fact Sheet: Women's Health and Cancer Rights Act. [US DOL Web site]. Available at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/whcra.pdf. Accessed July 09, 2024.

Up to Date. Lymphedema: Prevention and treatment. 06/16/2014. [Up to Date Web site]. Available at: http://www.uptodate.com [via subscription only]. [The link to this reference is no longer active on the UpToDate Web site.]. Accessed October 10, 2016.

Vignes S, Blanchard M, Arrault M, et al. Intensive complete decongestive physiotherapy for cancer-related upper-limb lymphedema: 11 days achieved greater volume reduction than 4. Gynecol Oncol. 2013;131(1):127-130.

Whitaker J. Best practice in managing scrotal lymphoedema. Br J Community Nurs. 2007;12(10):S17-18, 20-21.

Zuther JE, Norton S. Lymphedema Management: The Comprehensive Guide for Practitioners. 3rd edition. Head and Neck Lymphedema. 2009. Stuttgart, Germany; New York, NY. Thieme.

Coding

CPT Procedure Code Number(s)
97110, 97140
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
I89.0 Lymphedema, not elsewhere classified

I97.2 Postmastectomy lymphedema syndrome

Q82.0 Hereditary lymphedema
HCPCS Level II Code Number(s)
THE FOLLOWING CODE IS USED TO REPRESENT ALL COMPLETE DECONGESTIVE THERAPY (CDT) SERVICES

S8950 Complex lymphedema therapy, each 15 minutes
Revenue Code Number(s)
0420 General Classification/Physical Therapy

0430 General Classification/Occupational Therapy


Coding and Billing Requirements

Policy History

12/30/2014
12/30/2014
7/24/2024
MA07.042
Medical Policy Bulletin
Medicare Advantage
No