Lymphedema Compression Supplies: Denial or Insufficient Coverage Reporting Form

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The information you provide will assist the Lymphedema Advocacy Group in making future improvements to insurance coverage for lymphedema treatment supplies and services. Responses will be kept confidential.

To learn more about our group or to contact us, please visit our website.

Email *

Your Name *

What is the cause of your lymphedema?

We are asking because some states have congenital anomaly laws (primary lymphedema is a congenital anomaly) and the Women's Health and Cancer Rights Act provides certain rights to women with breast cancer-related lymphedema.

Breast Cancer-related Lymphedema (female only)

Primary Lymphedema

Other or Unknown

Your State *

State in which your insurance policy is based if different from the state you live in.

What type of insurance do you have?

Select your primary insurance type, if you have more than one policy.

Traditional Medicare

Medicare Advantage

Medicaid

CHIP

TriCare

VA Healthcare

Private (ACA health exchange plan)

Private (self-funded plan)

Private (all other plans)

If your primary insurance is a Medicare Advantage plan, what company administers it? For example, United Health Care, Aetna, etc.

If your primary insurance is a private plan, what company administers it? For example, United Health Care, Aetna, etc.

If you have a secondary insurance or supplemental plan please list that here.

What lymphedema treatment supply or service are you being denied coverage for or receiving insufficient coverage for? Just a short answer, you will be able to provide more details later. *

What was the date of service? Just the month and year are sufficient, and note that we are only tracking denials for compression garments ordered on or after January 1, 2024 (which is the date the Lymphedema Treatment Act went into effect) or lymphedema-related medical services sought after that date. *

Have you filed an appeal? We strongly encourage you to do so. Many patients win on appeal, and this documentation of the denial can help with future policy changes. *

Yes

No, but I plan to

What was the reason given for the denial? Please provide as many details as you feel comfortable sharing.

PLEASE BE ADVISED:

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.

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

Thank you for helping us to improve patient access to lymphedema treatment supplies and services!

A copy of your responses will be emailed to the address you provided.

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