D46. US Insurance Coverage of Lymphatic Microsurgical Preventing Healing Approach: A Critical Review

Abstract

PURPOSE: Breast-cancer-related lymphedema (BCRL) is a chronic, debilitating condition that is associated with patients who have undergone axillary lymph node dissection (ALND). Recently, Lymphatic Microsurgical Healing Approach (LYMPHA), a prophylactic microsurgical lymphovenous bypass technique, has been developed to prevent BCRL with promising results. However, insurance coverage is often denied. We investigated current coverage policies for LYMPHA among the top insurance providers in the United States. METHODS: Insurers were selected by identifying 50 companies with the largest market share and cross-referencing them with companies with greatest enrollment per state. Cross-sectional evaluation was performed on publicly available LYMPHA policies through a web-based search or phone call. Coverage status, coverage criteria, and exclusion rationale were collected and analyzed using descriptive statistics. RESULTS: Of the 63 insurers queried, 42.9% (n=27) do not have any public policies regarding LYMPHA coverage. Of those that do have a coverage policy (57.1%; n=36), 75.0% (n=27) deny coverage and 25.0% review claims on a case-by-case basis. In 21 of the coverage denials, LYMPHA was considered investigational, not standard practice, or to have insufficient published evidence. CONCLUSION: LYMPHA is known to significantly decrease the rates of BCRL following mastectomy and ALND, yet over half of the major insurance providers in the United States currently deny coverage. Focus should shift towards sharing high-level evidence at the legislative level to increase insurance coverage and therefore access to lymphedema prevention for breast cancer patients.