Palmetto GBA
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Jurisdiction 11 Part B
Manual Lymphatic Drainage Therapy

Providers are responsible for documenting the medical necessity of services performed in relation to lymphedema therapy. The following information should be maintained by the provider to document the medical necessity of services for lymphedema and available to Palmetto GBA upon request:
  • A physician documented diagnosis of lymphedema
  • A statement as to the ability of the patient/caregiver to follow through with the continuation of treatment on a long term home treatment plan; a history and physical which addresses the cause of the lymphedema and any prior treatment
  • Symptoms that necessitate treatment
  • Measurement of the body part/extremity prior to treatment
  • Report of the progress of the therapy including additional measurements, expected outcome of treatment and the expected duration of treatment and
  • Response of the patient/caregiver to education and their ability to take over the responsibilities of the treatments
Palmetto GBA has determined that there is insufficient evidence-based peer-reviewed literature to conclude that the technique known as manual lymphatic drainage therapy improves health outcome for diagnoses other than the treatment of lymphedema (ICD-9 codes 457.0, 457.1, and 757.0). When lymphedema is documented, manual drainage therapy may be submitted with CPT code 97140. Manual lymphatic drainage therapy performed for other diagnoses is not considered reasonable and necessary for the treatment of Medicare patients and is not billable to Medicare under any existing CPT or HCPCS codes. 


last updated on 02/27/2013
ver 1.0.51