Clinical Review Criteria — Lymphedema Therapy and Training (Complete Decongestive Therapy; LVA)
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Clinical review criteria governing coverage and medical necessity for Complete Decongestive Therapy (CDT) and the payer stance on Lymphatic Venous Anastomosis (LVA) for lymphedema for Kaiser Foundation Health Plan of Washington members and their providers.
MPC approved to retire clinical criteria due to low utilization; 60-day notice required, effective 09/01/2026.
INTC Review for Lymphovenous Anastomosis (LVA) (LYMPHA) for Prevention of Lymphedema from 02/01/2021 was added.
Complete Decongestive Therapy (CDT) is considered medically necessary when applicable policy criteria are met and is linked to specified CPT/HCPCS procedure codes.
Lymphatic Venous Anastomosis (LVA) including LYMPHA is considered not medically necessary.
Coverage and Medical Necessity Criteria
inv-01: Initial CDT coverage
Complete Decongestive Therapy is considered medically necessary if ALL of the following are met:
inv-02: Extended/continued CDT
Continued therapy may be indicated if ONE of the following are met:
inv-03: LVA (not supported)
Lymphatic Venous Anastomosis (LVA) statement:
inv-04: Complete Decongestive Therapy (CDT)
Complete Decongestive Therapy (CDT) coverage statement
Associated CPT/HCPCS examples include 97140, 97535, and S8950.
inv-05: LVA/LYMPHA (Not Medically Necessary)
Lymphatic Venous Anastomosis (LVA/LYMPHA) coverage statement
Available studies are small, heterogeneous, and at high risk of bias; overall quality of evidence is low despite some reports of reduced lymphedema incidence.
Complete Decongestive Therapy (CDT) is not covered when the requested services meet any of the following exclusions: therapy that is limited to exercise or elevation only and does not constitute CDT; therapy that does not include ongoing patient education; treatments intended principally to provide a temporary benefit; or when the patient or caregiver cannot learn CDT techniques within a reasonable time.
Lymphatic venous anastomosis procedures, commonly billed as CPT 1019T or as an unlisted procedure such as 38999, are explicitly identified in this policy as not medically necessary and therefore excluded from coverage. Codes listed may not be all-inclusive; verify authorization requirements by plan using the Pre-authorization Code Check.
The policy’s evidence review concluded that the body of literature on Complete Decongestive Therapy is limited: available studies provide low-quality or insufficient evidence regarding superiority of CDT over alternatives for lymphedema reduction, and overall CDT does not meet the Kaiser Permanente Medical Technology Assessment Criteria based on the current evidence summary.
Restating the policy position: Lymphatic Venous Anastomosis (LVA), including LYMPHA, is considered not medically necessary and is therefore not covered under this policy.
Relevant CPT / HCPCS Codes and Billing Categories
Provider Steps, Authorization & Documentation
Prior Authorization Required for CDT
Authorization required when documentation shows diagnosis and order for CDT training. CDT is medically necessary only when the treating or consulting practitioner documents primary or secondary lymphedema and specifically orders CDT training, and services are provided by a licensed PT/OT trained in CDT. Verify plan-specific preauthorization requirements prior to scheduling services.
Prior Authorization & Denial Risk for LVA/LYMPHA
Lymphatic venous anastomosis (LVA/LYMPHA) procedures are considered not medically necessary; preauthorization may still be required by plan and claims are at high risk for denial. Confirm authorization rules for the specific plan and use the Pre-authorization Code Check when available.
Confirm Prior Authorization for CDT Services
Confirm plan-specific preauthorization requirements prior to services. Even when CDT meets medical necessity criteria, many plans require prior authorization — verify for the member's plan and obtain approval before initiating treatment.
- Use Pre-authorization Code Check to verify authorization requirements by plan type
- Document the treating/consulting practitioner order and diagnosis in the authorization request
Non-CDT or Inadequate Capacity — Not Covered
Requests that are limited to exercise/elevation only, lack ongoing patient education, or involve patients/caregivers who do not have the capacity to learn CDT techniques are not supported and are NOT covered as CDT.
- Examples: exercise-only programs, temporary-benefit–only treatments, or education-only requests without CST components
- If patient/caregiver lacks capacity to learn techniques within a reasonable time, CDT is not appropriate
Documentation Guidance for CDT and LVA
Include supporting clinical documentation with claims and authorization requests to demonstrate medical necessity for CDT: treating/consulting practitioner diagnosis and specific order for CDT training, recent clinical notes, radiology if applicable, and documentation that PT/OT providing CDT has appropriate training.
- Required documentation: diagnosis, practitioner order for CDT, evidence of therapist CDT training
- Send last 6 months of clinical notes from requesting provider and/or specialist
- Include last 6 months of radiology if applicable
- When billing, include applicable CPT/HCPCS codes (97140, 97535, S8950) and supporting documentation
Step Therapy
No step therapy requirements for CDT are specified in this document. Verify any plan-level step therapy programs separately if concerned.
- If a plan imposes step therapy, confirm requirements via the plan's authorization resources
Key Terms and Definitions
Clinical Background and Evidence Summary
Complete Decongestive Therapy (CDT) is a multimodal, conservative treatment approach for lymphedema that combines manual lymphatic drainage (MLD), compression bandaging, exercise, and skin care. CDT is typically delivered in an intensive treatment phase (daily over approximately 2–4 weeks) focused on reducing limb volume and edema, followed by a maintenance phase emphasizing patient or caregiver self-management using compression garments, self-bandaging, exercise, and self-administered MLD. The overall aims of CDT are to reduce lymphedema, improve range of motion, and lower the risk of cellulitis.
Document Changes and Revision Notes
MPC approved retirement of the clinical criteria due to low utilization; 60-day notice required with an effective date of 2026-09-01.
Policy format was updated for clarity.
INTC review for Lymphovenous Anastomosis (LVA/LYMPHA) for prevention of lymphedema (02/01/2021) was added to the policy.
MTAC review for Complete Decongestive Therapy for the treatment of lymphedema was added.
MPC approved expansion of criteria to treat members with lymphedema caused by diagnoses other than cancer.
Hayes Technology Brief review was added to the policy record.
CDT and LVA criteria were merged into a single document under Lymphedema Therapy.
Criteria were completely revised to mirror Medicare guidelines supporting payment for comprehensive decongestive therapy only.
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