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A.7.01.173
Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of secondary lymphedema. Lymphedema is associated with a significant impact on quality of life, and there is no cure for lymphedema. Axillary reverse mapping, also called reverse lymphatic mapping, has been developed with the intent of sparing axillary lymph nodes and lymphatics during breast cancer surgery, minimizing disruption and potentially reducing the risk of subsequent lymphedema development.
Lymphedema
Lymphedema is an accumulation of fluid due to a disruption of lymphatic drainage. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema), but is most often caused by acquired damage to the lymphatic system (secondary lymphedema). Breast cancer treatment is one of the most common causes of secondary lymphedema. Specific treatment-associated risk factors associated with lymphedema development include:
Lymphadenectomy
Dissection or disruption of axillary lymph nodes; increasing the number of dissected/disrupted lymph nodes increases lymphedema risk
Radiation therapy.
The risk of breast cancer-related lymphedema is also increased in overweight or obese individuals, and in those with postoperative infections. Studies have suggested that Black breast cancer survivors are nearly 2.2 times more likely to develop breast cancer-related lymphedema compared to White breast cancer survivors. These observations may be linked to racial disparities with regards to access to treatment and the types of treatments received. Black women are more likely than White women to undergo axillary lymph node dissection, which is associated with greater morbidity than the less invasive sentinel lymph node biopsy. While this may be explained in part by Black individuals having a higher likelihood of being diagnosed with more aggressive tumors, there is evidence that even when adjusting for stage and grade of tumors, Black women are more likely to undergo axillary lymph node dissection, putting Black women at greater risk of breast cancer-related lymphedema. Additionally, Black breast cancer survivors, on average, have higher body mass indexes than White breast cancer survivors, which could contribute to the development of lymphedema in this setting as well.
Development of lymphedema may take months or years following breast cancer treatment, and the true prevalence of breast cancer-related lymphedema is unclear. Systematic reviews have found lymphedema rates up to 13% in individuals undergoing sentinel lymph node biopsy (SNLB) and as high as 77% in those undergoing axillary lymph node dissection (ANLD). The addition of radiation therapy to SNLB or ANLD may also increase risk of lymphedema. A prospective study of 1,815 individuals published in 2020 found a 5-year cumulative incidence of breast cancer-related lymphedema of 9.5%, which ranged widely from 8% to 30% when stratified according to type of treatment. The lowest incidence of lymphedema was found among those undergoing SLNB only (8%), increasing to 11% for SNLB + regional lymph node radiation, 25% for ANLD only, and 30% for ANLD + RLNR. While SNLB was associated with a lower lymphedema risk, some risk remains, particularly for those with multiple positive axillary nodes for whom the standard for care is ANLD with or without radiation.
Early and ongoing treatment of lymphedema is necessary. Conservative therapy may consist of several features depending on the severity of the lymphedema. Patients are educated on the importance of self-care including hygiene practices to prevent infection, maintaining ideal body weight through diet and exercise, and limb elevation. Compression therapy consists of repeatedly applying padding and bandages or compression garments. Manual lymphatic drainage is a light pressure massage performed by trained physical therapists or patients designed to move fluid from obstructed areas into functioning lymph vessels and lymph nodes. Complete decongestive therapy is a multiphase treatment program involving all of the previously mentioned conservative treatment components at different intensities. Pneumatic compression pumps may also be considered as an adjunct to conservative therapy or as an alternative to self-manual lymphatic drainage in patients who have difficulty performing self-manual lymphatic drainage. In patients with more advanced lymphedema after fat deposition and tissue fibrosis have occurred, palliative surgery using reductive techniques such as liposuction may be performed.
Axillary Reverse Mapping
Axillary reverse mapping (ARM), involves subcutaneous administration of blue dye, fluorescence (i.e., indocyanine green), or radioisotopes to allow for visualization of the lymphatic drainage pathways of the arm and breast. This visualization is intended to distinguish and enable preservation of axillary lymph nodes and lymphatics in individuals undergoing SLNB and/or ANLD. It is believed that because the axilla and breast have mostly separate drainage pathways, the risk of lymphedema is reduced by avoiding the removal of lymph nodes and lymphatics that only drain the axilla identified through ARM. In the event that ARM reveals that the axillary nodes cannot be spared, for example due to crossover of sentinel and axillary nodes, lymphatic physiologic microsurgery has been explored as a method to preserve the axillary nodes, though evidence is limited (see the Surgical Treatments for Breast Cancer-Related Lymphedema medical policy).
Axillary reverse mapping for lymphedema is adjunctive to a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration (FDA). Mapping agents used to visualize lymphatic pathways (e.g. isosulfan blue, indocyanine green) may be subject to FDA regulation.
Related medical policies –
Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.
Axillary reverse mapping/reverse lymphatic mapping performed during axillary lymph node dissection to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.
Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
07/01/2023: New policy added. Approved by the Medical Policy Advisory Committee.
01/05/2024: Policy reviewed; no changes.
01/31/2025: Policy reviewed; no changes.
08/15/2025: Code Reference section updated to remove CPT codes 38792, 38900, and HCPCS code C9756. Added CPT code 38999 to the Investigational Codes table.
Blue Cross Blue Shield Association policy # 7.01.173
This may not be a comprehensive list of procedure codes applicable to this policy.
Investigational Codes
Code Number | Description |
CPT-4 | |
38999 | Unlisted procedure, hemic or lymphatic system |
HCPCS | |
ICD-10 Procedure | |
ICD-10 Diagnosis |
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