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This letter is in reference to your claim to receive medical benefits to treat your Lymphedema as a consequential illness resulting from the treatment for your accepted condition of breast cancer, under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).


Medical evidence includes a letter dated January 1, 2015, in which Dr. John Smith stated that you have been diagnosed with breast cancer and had to undergo a radical mastectomy. As such, you developed lymphedema as a result of your radical mastectomy.


Based on Dr. Smith’s statement, the medical evidence is sufficient to establish that your lymphedema is a result of treatment for your covered illness, breast cancer and is accepted as a covered consequential illness under Parts B and E of the EEOICPA guidelines. Medical benefits are approved for the treatment of your lymphedema (ICD-9 Code 457.1) retroactive to July 1, 2013, the date of filing for your breast cancer.


Covered medical services are payable in accordance with fee schedules and medical policy of the EEOICPA. The policy includes coverage of medical appointments, hospitalizations, appliances, supplies and drugs that are prescribed by a qualified physician and approved by the EEOICPA.


When you receive medical treatment you should show this letter to the medical provider you wish to designate as your treating physician and any other authorized medical provider who may treat you for your covered illnesses. Most physicians, hospitals, durable medical equipment providers, and other health care providers will bill the EEOICPA directly so that you will not have to pay for medical treatment covered under the Program. To bill directly, providers must be enrolled in the program. For information about enrollment and billing procedures, providers may contact the Program at the address and telephone number listed at the end of this letter.


Note: If the EEOICPA pays less than the billed amount (in accordance with the fee schedule), you are not responsible for payment of the difference to a provider. Providers (and claimants) may submit requests for reconsideration of fee determinations in writing, with accompanying documentation to the address supplied at the end of this letter.


The EEOICPA will reimburse you for the cost of covered services/items that you have personally paid, providing that you submit appropriate documentation to the Program’s billing address. However, bills and requests for reimbursement must be sent to EEOICPA within one year after the end of the calendar year in which the service or supply was provided, or within a year after the end of the calendar year in which the condition was accepted, whichever is later.


To request reimbursement of medical expenses associated with treatment of your accepted illnesses you are required to complete and submit the OWCP-915 form, Claim for Medical Reimbursement. You should also complete and submit the OWCP-957, Medical Travel Refund Request form with appropriate receipts when seeking reimbursement for travel expenses covered under the program. Both OWCP-915 and OWCP-957 forms (copies enclosed for convenience) include instructions for when you should complete these forms and the documentation required to process your request for reimbursement.


All requests for reimbursement of covered treatment related expenses including travel are to be mailed to:


Division of Energy Employees Occupational

Illness Compensation

P.O. Box 8304

London, KY 40742-8304


If providers have questions regarding submission or payment of bills, or require any other medical bill program assistance, they may contact a representative at toll free 1-XXX-XXX-XXXX.






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Claims Examiner




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(Name) Date