DESCRIPTION
Lipedema is a rare disorder of adipose tissue of the extremities that primarily affects females and can be misdiagnosed as obesity or lymphedema. The cause is unknown; however, it is associated with hormonal and hereditary influences. It is a distinct entity that can be differentiated from obesity and lymphedema, although it can also progress to involve the venous and lymphatic systems increasing the difficulty of diagnosis. In most cases, lipedema affects the lower extremities, leaving ankle and feet unaffected with minimal pitting edema resembling “stovepipe” enlargement of the legs with a sharp demarcation between normal and abnormal tissue at the top of the ankle, referred to as the “cuff sign.” Lipedema isolated to the arms without involvement of the legs is extremely rare.
First-line treatment for lipedema is conservative therapy (i.e., exercise, dietary counseling, and psychosocial therapy) to reduce severity of symptoms. Liposuction or lipectomy may be considered to permanently remove subcutaneous fat deposits and reduce pain, and un-restrict movement to improve quality of life.
NOTE: Lipectomy is a benefit contract exclusion when performed as a cosmetic service.
POLICY
Liposuction or lipectomy for lipedema is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Liposuction or lipectomy for lipedema is considered medically appropriate if ALL of the following are met:
Treatment is indicated if ALL the following are met:
Pain and tenderness upon palpation in the affected area
Bruises Easily
Physical function impairment (i.e., difficulty ambulating, performing daily activities)
Absence of pitting edema unless there is coexisting lymphedema
Negative Stemmer sign (Stemmer sign is negative when a fold of skin can be pinched and lifted at the base of the second toe or middle finger)
Failed four consecutive months of medical management (i.e., weight loss, limb elevation, conservative treatment with compression garments)
Documentation of an assessment by the referring primary care provider or specialist in vascular conditions (not by treating surgeon) confirms that lipedema is an independent cause of the existing functional impairment
Photographs confirm the presence of bilateral symmetric adiposity (fat accumulation) in the affected Extremities
Documentation that the affected area to be treated has not undergone this treatment previously
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 several distinct differences between the presentation of lipedema and primary lymphedema which are provided in the table below:
Lipedema |
Lymphedema |
Symmetric (buttocks involved) |
Not symmetric |
Foot not involved |
Foot involved |
Not pitting |
Pitting edema |
Stemmer sign negative |
Stemmer signs positive |
Tissue feels rubbery |
Tissue feels firmer (starting stage 2 lymphedema) |
Painful to touch |
Generally, not painful to touch |
Easy bruising |
Generally, not bruising |
Hormonal disturbances frequent |
Generally, no hormonal disturbance |
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (11:2022). Liposuction for Lipedema and Lymphedema. (7.01.169). Retrieved March 1, 2023 from https://www.evidencepositioningsystem.com/. (17 articles and/or guidelines reviewed)
Dadras, M., Mallinger, PJ., Corterier, CC., Theodosiadi, S., & Ghods, M. (2017). Liposuction in the treatment of lipedema: A longitudinal study. Archives of Plastic Surgery, 44 (4): 324-331. (Level 4 evidence)
Kruppa, P., Lakovos, M.D., Schmidt, J., Infanger,M., & Ghods, M. (2022). A 10-year retrospective before – and – after study of lipedema surgery: patient – reported lipedema-associated symptom improvement after multistage liposuction. Journal of the American Society of Plastic Surgeons, 149 (3), 529e-541e. Abstract retrieved from https://journals.lww.com/plasreconsurg/Abstract/2022/03000/A_10_Year_Retrospective_before_and_after_Study_of.43.aspx.
National Institute for Health and Care Excellence. (2022, March). Liposuction for chronic lipoedema. Retrieved March 1, 2023 from https://www.nice.org.uk/.
National Library of Medicine. (2019, June). Liposuction for the treatment of lipedema: A review of clinical effectiveness and guidelines. Retrieved March 1, 2023 from https://www.ncbi.nlm.nih.gov/.
Podda, M., Kovacs, M., Hellmich, M., Roth, R., Zarrouk, M., Kraus, D., et al. (2021). A randomised controlled multicentre investigator-blinded clinical trial comparing efficacy and safety of surgery versus complex physical decongestive therapy for lipedema (LIPLEG). Trials, 22 (758) https://doi.org/10.1186/s13063-021-05727-2. (Level 1 evidence).
Schmidt, J., Kruppa, P., Georgiou, L., & Ghods, M. (2021). Management of large volume liposuction in lipedema patients with von Willebrand disease: A systematic review and treatment algorithm. Abstract retrieved March 1, 2023 from PubMed database.
Shavit, E., Wollina, U., & Alavi, A. (2018). Lipoedema is not lymphoedema: a review of current literature. International Wound Journal, 15 (6), 857-1053. (Level 5 evidence)
Van de Pas, CB., Boonen, R.SM., Stevens, S., Willemsen S., Valkema, R., & Neumann, M. (2019). Does tumescent liposuction damage the lymph vessels in lipoedema patients? Phlebology, 35 (4), 221-291. (Level 5 evidence)
Winifred S. Hayes, Inc. Evolving Evidence Review. (2023, March). Liposuction for the Treatment of Lipedema. Retrieved March 1, 2023 from www.Hayesinc.com/subscribers. (21 articles and/or guidelines reviewed)
Wounds UK. (2017, March). Best practice guidelines the management of lipoedema. Retrieved March 6, 2023 from https://www.wounds-uk.com/resources/details/best-practice-guidelines-management-lipoedema.
ORIGINAL EFFECTIVE DATE: 8/1/2023
MOST RECENT REVIEW DATE: 8/1/2023
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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