DESCRIPTION
Lymphedema is an abnormal accumulation of interstitial fluid and fibroadipose tissue in the subcutaneous tissues or body cavities. Accumulation of interstitial lymph fluid occurs when the accumulation of lymph exceeds the capacity of the system drain, causing hypertrophy of fat cells. It can cause an increased risk of infection that can cause physical impairment, negative impact on the quality of life and adverse psychosocial effects. Primary lymphedema may occur due to congenital anomalies or an inherited condition. Secondary lymphedema has a variety of causes that reduce lymph drainage (i.e., surgical removal of lymph nodes, post-radiation fibrosis, scarring of lymphatic channels, obesity, chronic lymphatic overload). The most common causes are acquired by surgery and/or radiation therapy for cancer.
A few individuals fail conservative treatment (e.g., skin care, exercise, weight reduction, compression garments, manual lymphatic drainage, intermittent pneumatic compression) and surgical options may be recommended. Lipectomy or liposuction (the removal of fatty tissue) is being considered as a surgical treatment option when an individual has failed conservative treatment. The role of lipectomy or liposuction to treat lymphedema is to remove the fatty tissue that is within the subcutaneous tissue or a body cavity causing the backup of interstitial fluid.
It is imperative for an individual to continue to wear compression garments post-surgery to maintain the benefits of treatment by reducing rapid reaccumulation of fibrofatty tissue.
NOTE: Lipectomy is a benefit contract exclusion when performed as a cosmetic service.
POLICY
Lipectomy or liposuction for lymphedema is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Lipectomy or liposuction for lymphedema is considered medically appropriate if ALL the following are met:
Treatment is indicated if ALL the following are met:
Physical function impairment (i.e., difficulty ambulating, performing activities of daily living)
Failed three consecutive months of medical management (e.g., compression garments, manual lymph drainage)
Photographs, when requested, to document the affected areas are consistent with the diagnosis of lymphedema
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
There are two main staging methods for lymphedema: The International Society of Lymphology (ISL) scale and Campisi scale. The International Society of Lymphology staging guidelines for lymphedema states:
Stage 0: Latent or Subclinical
Impaired lymphatic transport
No evident swelling/edema, subtle changes in tissue fluid/composition
Changes in subjective symptoms
May last months or years before progression
Stage I: Spontaneously Reversible
Early accumulation of protein-rich fluid
Pitting edema, no evidence of dermal fibrosis
Subsides with elevation
Stage II: Spontaneously Irreversible
Accumulation of protein-rich fluid
Pitting edema may progress to nonpitting as excess fat and fibrosis develop
Does not resolve with elevation alone
Stage III: Lymphostatic Elephantiasis
Nonpitting
Significant fibrosis
Trophic skin changes such as fat deposits, acanthosis, and warty overgrowths
Tumescent liposuction has been proposed as the next treatment when conservative care fails. It is a technique that uses local anesthetic and a vibrating cannula associated with power-assisted liposuction to remove the fat. Waterjet assisted liposuction can also be used. It uses a pressurized stream of saline to dislodge the fat and more gently loosen and remove the fat cells.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (2.2024). Liposuction for Lymphedema and Lymphedema (7.01.169). Retrieved March 18, 2024, from www.bcbsaoca.com/eps. (16 articles and/or guidelines reviewed)
Carl, H.M., Walia, G., Bello, R., Clarke-Pearson, E., Hassanein, A.H., Cho, B., et al. (2017). Systematic review of the surgical treatment of extremity lymphedema. Journal of Reconstructive Microsurgery, 33 (6), 412-425. (Level 4 evidence)
Chang, D.W., Dayan, J., Greene, A.K., MacDonald, J.K., Masia, J., Mehrara, B., et al. (2021). Surgical treatment of lymphedema: A systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plastics and Reconstructive Surgery, 147 (4), 975-993. Abstract retrieved January 14, 2022 from PubMed database.
Forte, A.J., Huayliani, M.T., Boczar, D., Ciudad, P., & McLaughlin, S.A. (2019). Lipoaspiration for the treatment of lower limb lymphedema: A comprehensive systematic review. Cureus, 11 (10), e5913. (Level 4 evidence)
Hoffner, M., Ohlin, K., Svensson, B., Manjer, J., Hansson, E., Troeng, T., et al. (2018). Liposuction gives complete reduction of arm lymphedema following breast cancer treatment – A 5-year prospective study in 105 patients without recurrence. Plastic and Reconstructive Surgery. Global Open, 6 (8), e1912. (Level 5 evidence)
National Institute for Health and Clinical Evidence (NICE). (2022, April). Liposuction for chronic lymphoedema. Retrieved February 8, 2023, from http://www.nice.org.uk.
The International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the International Society of Lymphology. Retrieved January 14, 2022, from https://journals.librarypublishing.arizona.edu/lymph/article/id/4649/.
Tyker, A., Franco, J., Massa, S.T., Desai, S.C., Walen, S.G. (2019). Treatment for lymphedema following head and neck cancer therapy: A systematic review. American Journal of Otolaryngology, 40 (5), 761-769. Abstract retrieved January 18, 2022, from PubMed database.
Winifred S. Hayes, Inc. Medical Technology Directory. (2020, October; last update search October 2023). Liposuction for the reductive surgical treatment of lymphedema. Retrieved March 18, 2024, from www.Hayesinc.com/subscribers. (45 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 6/1/2022
MOST RECENT REVIEW DATE: 4/11/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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