Kathy Bates and lymphedema after breast cancer: who pays for the physical therapy and the sleeve?

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

In April 2016, Kathy Bates told CBS News that she had undergone breast cancer surgery in 2012, a double mastectomy in which 19 lymph nodes were removed, and that lymphedema came afterwards: the chronic swelling of the arm that sets in when lymphatic drainage from the armpit is interrupted. The actress is a spokesperson for the Lymphatic Education & Research Network (LE&RN), and on 9 April 2019 she spoke on its behalf before an appropriations subcommittee of the House of Representatives. To CBS, she explained the choice: if she could use her fame for something real, that was what she wanted to do. To MedlinePlus magazine, published by the US National Institutes of Health (Spring 2022 issue), she said that the lymphedema was under control, that she still wears compression sleeves when she travels by plane or exerts herself, and added that she can afford the appointments, the compression garments and the therapy, and that many people cannot. The account is hers and ends there: nothing is known, and nothing is asserted here, about the physicians, the services or the clinical choices of that journey.

That sentence has three items: appointments, compression garments and therapy. In Brazil, two of them have a clear rule, in the SUS (Brazil’s public health system) and in health plans. The third, the sleeve, is the point at which medicine and Brazilian law classify the same object in different ways, and it is the one the article deals with most.

A sequela with no discharge date

The international reference on how frequent the problem is comes from the meta-analysis by DiSipio, Rye, Newman and Hayes (Lancet Oncology, 2013). In 72 studies published between 2000 and 2012, the incidence of arm lymphedema was 16.6%, and 21.4% in the prospective cohorts, which measure it better. It appeared to rise until two years after surgery and was about four times higher with axillary lymph node dissection (19.9%) than with sentinel lymph node biopsy (5.6%). In the authors’ words, “more than one in five women who survive breast cancer will develop arm lymphoedema”.

The longest Brazilian dataset shows that the risk does not end at two years. Ribeiro Pereira, Koifman and Bergmann, researchers at the National School of Public Health of Fiocruz, followed 964 women who underwent axillary dissection and published the result in The Breast in 2017: the cumulative incidence of lymphedema was 13.5% at two years, 30.2% at five and 41.1% at ten, higher among those who had radiotherapy (hazard ratio 2.19), those who were obese and those who had a seroma after surgery. The diagnostic criterion differs from that of the meta-analysis, and the population consists only of axillary dissection, but the lesson is the same: the arm needs surveillance for many years.

The 2023 consensus of the International Society of Lymphology (ISL), the main clinical reference on the subject, records that lymphedema most often becomes a chronic condition, generally incurable, and classifies it in stages: stage 0 is latent, in which swelling is not yet evident; stage III is lymphostatic elephantiasis. It is a treatable disease, not a curable one: the goal is to reduce the volume and keep it reduced, and it is the maintenance that lasts a lifetime.

Treatment has two phases, and the sleeve is in the second

The standard treatment is complex decongestive therapy, which the ISL consensus describes in two phases. The first, intensive phase comprises skin care, a specific light manual massage (manual lymphatic drainage), muscle-pumping exercises and compression, usually with multilayer bandaging. The second, maintenance phase comprises “compression by a low-stretch elastic stocking or sleeve”, skin care, continued exercise and drainage “as needed”. Prescribing the garment to maintain the reduction obtained, the document says, is essential for long-term care. In medicine, the sleeve is not an accessory: it is phase two of the treatment.

Lymphatic drainage, which many patients associate with the treatment, has more modest evidence than its reputation. The systematic review by Thompson and colleagues (Journal of Cancer Survivorship, 2021), with 17 studies, found conflicting results and a signal of additional benefit only in mild lymphedema; in moderate to severe cases, drainage may add nothing to complete decongestive therapy. What is asked of the SUS or of the health plan is the prescribed treatment plan, not an isolated technique.

Compression also appears before the disease sets in. Stout Gergich and colleagues (Cancer, 2008) measured the arms of 196 women before surgery and every three months afterwards; in the 43 who had an increase in volume above 3%, about four weeks of a compression garment reduced the volume, and the reduction held. In the PREVENT trial (Ridner and colleagues, Lymphatic Research and Biology, 2022), with 963 randomized patients, the initial change detected on surveillance led to four weeks of a compression sleeve and glove; among those who received the intervention, progression to chronic lymphedema was 7.9% in the group monitored by bioimpedance and 19.2% in the group monitored by tape measure. The ISL consensus adopts prospective surveillance, with measurement of both arms before surgery, because identifying and treating early offers greater therapeutic success and potential cost savings.

What the guidelines say

The British guideline on early and locally advanced breast cancer (NICE NG101) directs that people undergoing treatment be informed of the risk of lymphedema (recommendation 1.14.1), that those who develop it be referred to a specialist service “as soon as possible” (1.14.6), and that compression therapy be offered as the first step in the management of lymphedema (1.14.9). In the same section, it sets a limit: do not offer compression as a risk-reduction measure to those who are merely at risk, without lymphedema (1.14.4). The sleeve is not for every woman who has had surgery; for those who have the disease, it is first-line treatment.

The guideline also directs that advice be given on cellulitis and deep vein thrombosis (1.14.7), because not every swollen arm is lymphedema: sudden, painful, red swelling, or swelling with fever, calls for medical attention the same day. Buying a sleeve on one’s own, without measurement or prescription, can delay another diagnosis and leaves the coverage request without a document.

In the SUS: physical therapy is in the law; the garment depends on the network

The starting point is Lei 12.732/2012, which guarantees cancer patients “all necessary treatments”, free of charge, in the SUS (art. 1), and the principle of comprehensive care in Lei 8.080/1990 (the Organic Health Law), the “articulated and continuous set of actions and services” (art. 7, II). Since May 2026 there has been a specific rule: Lei 15.267, of 21 November 2025, published three days later and in force after 180 days, rewrote art. 1 of Lei 9.797/1999, and women with breast mutilation resulting from cancer treatment became entitled to reconstructive surgery “as well as to physical therapy treatment, when indicated by the treating physician and in accordance with regulations of the Ministry of Health, for rehabilitation and prevention of post-treatment complications”. The sole paragraph extends physical therapy to men treated for breast cancer.

“Prevention” means that physical therapy does not depend on the lymphedema already being established, which fits the surveillance model. And “in accordance with regulations” assigns to the Ministry of Health the task of saying how and where physical therapy will be provided, not whether it will be: the absence of detailed regulations does not allow the service to answer that the care does not exist. The procedure, moreover, already has a code. A technical opinion of the Rio de Janeiro judiciary’s technical support unit (NATJUS, No. 2161/2024, of 10 June 2024), on a patient with radical mastectomy, axillary dissection, radiotherapy and arm lymphedema, recorded SUS coverage under “physical therapy care for clinical oncology patients” (03.02.02.002-0) and warned that “excessive delay in starting physical therapy treatment may negatively compromise the prognosis”. Enforcement follows the path of the guide to what citizens can demand from the SUS (in Portuguese).

The compression garment is another story. The Care Network for Persons with Disabilities, created by Ordinance GM/MS 793/2012 with orthopedic workshops intended for the “dispensing, manufacture, fitting and maintenance of orthoses, prostheses and mobility aids” and with specialized rehabilitation centers, is today consolidated in Annex VI to Consolidation Ordinance No. 3/2017 and, since 2023, serves those who have a “long-term physical, mental, intellectual or sensory impairment”. A chronic lymphedema that limits the arm may qualify, but the door does not guarantee the item. Another opinion from the same unit (NATJUS No. 1123/2024, of 26 March 2024), on compression stockings for severe lymphedema of the legs, acknowledged the indication and recorded that the item “is not part of any official list of medicines and supplies” dispensed in the municipality and the state of Rio de Janeiro. The garment depends on the local network having standardized it; when it has not, what remains is an administrative request with a prescription and, if necessary, the courts, where the federal, state and municipal governments are jointly and severally liable (Tema 793 of the STF, the Supreme Federal Court).

In health plans: sessions without a cap, sleeve outside minimum coverage

In the private health-plan sector, Lei 9.656/1998 (the Health Plans Act) requires outpatient plans to cover “treatments and other outpatient procedures requested by the treating physician” (art. 12, I, b), and art. 18, V, of Normative Resolution (RN) 465/2021 of the ANS (the health-plan regulator) guarantees physical re-education and rehabilitation procedures, performed by a physiatrist or physical therapist, “in an unlimited number of sessions per year”. RN 541/2022, in force since 1 August 2022, revoked the utilization guidelines that placed conditions on sessions of physical therapy and of three other professions (art. 3), and ANS Technical Opinion No. 39/2024 repeats that those sessions, “whatever the patient’s health condition”, have no cap when indicated by the treating professional. Unlimited, however, is not indefinite: the health-plan operator may require a prescription, a goal and reassessment, as in rehabilitation after ACL surgery (in Portuguese). A technique outside the ANS list of mandatory coverage (the “rol”) follows art. 10, § 13, of Lei 9.656, which requires scientific evidence and a treatment plan, and there the Thompson review weighs against drainage on its own; the general route is in the guide on coverage denials (in Portuguese).

The sleeve meets another rule. Art. 10, VII, of Lei 9.656 excludes from the reference plan the “supply of prostheses, orthoses and their accessories not linked to the surgical act”, and § 1 entrusts the regulation of the exclusions to the ANS. In RN 465, art. 4, VI, defines an orthosis as “permanent or temporary material that assists the functions of a limb, organ or tissue”; art. 17, sole paragraph, VII, repeats the exclusion; and art. 19, VI, guarantees only “orthoses and prostheses linked to the surgical acts listed in the Annexes”. A sleeve for daily use, put on and taken off by the patient at home, fits the definition and is not linked to a surgical act. The ANS applied the same criterion to the special garments used in rehabilitation therapies (the so-called suits), which, according to Technical Opinion No. 25/2024, “are not subject to mandatory coverage because they use orthoses not linked to the surgical act”, and the STJ (the Superior Court of Justice) held, in general terms, that operators “are not obliged to bear the cost of prostheses and orthoses and their accessories not linked to a surgical act” (REsp 1.915.528/SP, Fourth Panel, decided on 28 September 2021). In the search of STJ case law carried out for the article, on 15 October 2026, no decision appeared on lymphedema or on compression garments.

There is an argument to the contrary, with a clinical basis: the sleeve is the maintenance of the treatment of a complication of another covered treatment, the oncological one, and the plan must cover the outpatient treatments requested by the treating physician. The obstacle is that the exclusion looks at the object, not at the purpose, and the ANS regulations confirm that reading; without a panel precedent setting it aside, it is an argument to be made case by case. Two situations fall outside the exclusion. Compression bandaging applied by the physical therapist during the session is part of the rehabilitation procedure, and is not the supply of an orthosis for home use. And if the contract provides for the garment, the contract governs: the law sets the minimum; it does not prohibit offering more.

Comparative law: three countries that treat the sleeve as treatment

The three examples were read in the official sources and show different paths: a statute for the public insurance program, a prescription in the national health service, and the catalog of the social insurance scheme.

1. United States: the law that made Medicare pay for the garment

Since 1998, the Women’s Health and Cancer Rights Act (29 U.S.C. § 1185b) has required a group health plan that covers mastectomy to cover, for the patient who elects reconstruction, “prostheses and physical complications of mastectomy, including lymphedemas”. The rule does not reach Medicare, the public insurance program for the elderly; for Medicare, the change came with section 4133 of the 2023 appropriations law (Consolidated Appropriations Act, 2023), the result of the patient campaign known as the Lymphedema Treatment Act, which created a benefit category for items “furnished on or after January 1, 2024”. The regulation (42 CFR § 410.36) includes standard and custom-fitted gradient compression garments, adjustable wraps and bandaging systems, and § 414.1680 sets the quantity: three daytime garments per affected limb every six months and two nighttime garments every two years.

2. England: the garment on the national health service’s prescription

In England, lymphedema sleeves and gloves, standard or made to measure, are listed in Part IXA (appliances) of the Drug Tariff, the NHS’s official reimbursement schedule, and can be prescribed on an ordinary national health service prescription. The technical bulletin of PrescQIPP, an organization that supports prescribing in the NHS (No. 192, 2019), advises that the patient receive two of each garment, one to wear and one to wash, with replacement every three to six months, after assessment by a trained professional. There, anyone being treated for cancer or for the effects of cancer treatment is entitled to a five-year exemption certificate that makes NHS prescriptions free of charge. Together with NICE recommendation 1.14.9, the sleeve is an item prescribed and replaced by the public system.

3. Germany: the social insurance catalog

In Germany, § 33 of Book V of the Social Code guarantees those insured under statutory health insurance the aids “necessary in the individual case to secure the success of the treatment, to prevent an imminent disability or to compensate for a disability”. The official catalog of those aids, maintained by the national federation of health insurance funds, has an entire group for compression therapy (Produktgruppe 17, updated on 26 May 2025): it includes compression stockings and arm sleeves, with or without a glove, provides for their use in edemas, including lymphedemas, “in the maintenance phase, to preserve the reduction in edema obtained”, allows made-to-measure flat-knit garments when the disease requires a firmer fabric, and sets, as a rule, a minimum durability of six months.

All three systems treat the compression garment as part of the treatment, with rules on quantity and replacement. Brazil, in 2025, amended the right law and added physical therapy to Lei 9.797, but said nothing about the garment; in the private health-plan sector, the sleeve remains classified as an excluded orthosis. The gap is a legislative choice, and it is in Congress, more than in the courts, that it tends to be resolved.

Liability and rights

Lymphedema is not, in itself, medical malpractice: it is a known risk of axillary surgery and of radiotherapy, which can arise with the best technique. What is required of those who treat is diligence, information and record-keeping. The Code of Medical Ethics prohibits failing to inform the patient of the diagnosis, the prognosis, the risks and the goals of treatment (art. 34) and failing to keep a legible medical record (art. 87). Lei 15.378/2026, the Patients’ Rights Statute, guarantees information that is “accessible, up to date and sufficient” to decide (art. 12, § 1), a second opinion at any stage of treatment (art. 18) and access to the medical record without having to give reasons (art. 19). It is in the medical record that what links the swelling to the treatment, years later, is found: the surgical report with the number of lymph nodes removed and the measurements of the arm.

Liability comes in when there is an avoidable omission in follow-up: the complaint of swelling that was recorded and not investigated, the cellulitis that was not recognized, the referral that was never made. The hospital, the clinic and the health-plan operator are strictly liable for the services that are their own (CDC, the Consumer Protection Code, art. 14); when the defect lies in the physician’s act, proof of the physician’s fault is required (art. 14, § 4). If the delay deprived the patient of a serious possibility of better control, the STJ allows compensation for the loss of a chance; the reference precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, decided on 4 December 2012), a case of inadequate treatment of breast cancer, not of lymphedema, whose headnote sets the limit: “The chance, however, can never reach the value of the thing lost”. Proof that surveillance would have changed the outcome, in the specific case, is a matter for expert evidence. At work, since malignant neoplasm is exempt from the qualifying period (Lei 8.213/1991, arts. 26, II, and 151), the disability benefit does not depend on the number of contributions; protection against dismissal is covered in the article on breast cancer and work (in Portuguese).

Before deciding

Lymphedema has no discharge date, and the operator that answers that “the cancer treatment is already over” confuses the end of chemotherapy with the end of treatment. On both routes, the paperwork decides: the surgical report, the measurement of both arms, the prescription stating the phase of treatment and the goal, and the denial in writing. Physical therapy is a clear right in the SUS, under Lei 9.797, and in health plans, under RN 465, with no cap on sessions. In my view, the sleeve for daily use at home is caught by the exclusion in art. 10, VII, of Lei 9.656, and the patient should not count on an easy lawsuit to obtain it from the plan; the most useful step is to check the contract and, in the SUS, to request the garment, with a prescription, from the network’s rehabilitation center or orthopedic workshop. That legal answer does not change the clinical fact: the sleeve is treatment, and the three countries examined show that the gap is resolved by statute. If physical therapy was cut off, denied or never started, get in touch with the firm with the prescription and the written denial at hand: the analysis starts from those documents and does not replace medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).