Surgical Treatments for Lymphedema and Lipedema

POLICY NUMBER

L.7.01.440

DESCRIPTION

Lymphedema is an accumulation of fluid due to 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).

Lymphedema

Lymphedema can be subdivided into primary and secondary categories. Primary lymphedema has no recognizable etiology, while secondary lymphedema is related to a variety of causes including surgical removal of lymph nodes, post-radiation fibrosis, scarring of lymphatic channels, or congenital anomalies. There is no cure for lymphedema. However, physiologic microsurgical techniques such as lymphaticovenular anastomosis or vascularized lymph node transfer have been developed that may improve lymphatic circulation thereby decreasing symptoms and risk of infection.

Diagnosis and StagingA diagnosis of secondary lymphedema is based on history (e.g., cancer treatment, trauma) and physical examination (localized, progressive edema and asymmetric limb measurements) when other causes of edema can be excluded. Imaging, such as magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from others causes of edema in diagnostically challenging cases.

The table below lists the International Society of Lymphology (ISL) guidance for staging lymphedema based on “softness” or firmness” of the limb and the changes with elevation of the limb.

Recommendations for Staging Lymphedema

Management and TreatmentEarly 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 by 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 has occurred, palliative surgery using reductive techniques may be performed.

LipedemaLipedema is a rare disorder in which increased adipose tissue builds up under the skin causing non-pitting, symmetric, bilateral swelling of the lower extremities; the upper extremities can also be affected. Hands and feet characteristically do not swell. It primarily affects women. The cause of lipedema is unknown and there is currently no curative treatment for this condition. Signs and symptoms typically present at puberty, pregnancy, or menopause. Because of this, it is theorized that there is a hormonal influence on the disorder. Hereditary factors are also thought to play a role in its etiology. Lipedema is often painful and may present with bruising along with sensitivity to touch. This condition gradually worsens over time and may progress to a lipolymphedema due to the lymphatic load exceeding the lymphatic transport capacity. Lipedema is often misdiagnosed as obesity or lymphedema but does not generally respond to weight loss, exercise, or elevation of the limbs as do those disorders.

TreatmentTreatment is aimed at relieving the symptoms. Conservative care with combined decongestive therapy (manual lymphatic drainage and compression garments) is the mainstay treatment of choice. If there is an inadequate response to conservative or supportive measures, tumescent liposuction has been proposed as the next line of treatment. Tumescent liposuction is a technique whereby local anesthetic, such as diluted lidocaine and epinephrine, is injected into subcutaneous fat and a vibrating cannula associated with power-assisted liposuction removes the fat. Water-jet assisted liposuction is another method of liposuction that may be used to treat lipedema. This method uses a pressurized stream of saline to dislodge the fat and more gently loosen and remove the fat cells.

Related medical policies –

• Surgical Treatments for Breast Cancer-Related Lymphedema

POLICY

Liposuction for lipedema or lymphedema may be considered medically necessary to treat functional impairment when ALL the following criteria are met:

1. One of the following diagnoses:

   1. A diagnosis of lipedema with all of the following:

      1. Absence of pitting edema from lipedema, AND

      2. Bilateral and symmetrical manifestation with minimal involvement of the feet, AND

      3. Disproportionate adipocyte hypertrophy of the extremities (including buttocks) in relationship to the trunk, AND

      4. Photographs of the area to be treated that document disproportional fat distribution consistent with diagnosis, AND

      5. There has been a lack of effect of weight loss measures as documented in the medical records through nutrition and medical interventions and clinic visits over six consecutive months, AND

      6. Negative Stemmer Sign, AND

      7. There is significant physical functional impairment, e.g., difficulty ambulating or performing activities of daily living, or medical complications such as recurrent cellulitis or skin ulcerations, AND

      8. Pressure induced pain and tenderness on palpation.

         OR

   2. A diagnosis of lymphedema with all of the following:

      1. Documentation supports stage II or greater lymphedema per the International Society of Lymphology scale, AND

      2. Other possible causes of edema have been ruled out (cardiac, kidney, liver, or thyroid dysfunction), AND

      3. There is significant physical functional impairment, e.g., difficulty ambulating or performing activities of daily living, or medical complications such as recurrent cellulitis or skin ulcerations. 

2. The individual has not responded to at least three to six consecutive months of conservative management to include each of the following: medical grade compression garments, complex decongestive lymphatic therapy (also referred to as manual lymph drainage), intermittent sequential pneumatic compression, (documentation of conservative management must be submitted), AND 

3. Treatment plan includes all the following:

   1. Assessment by the referring primary care provider or a specialist in vascular conditions (different from the treating surgeon) confirms that lipedema is an independent cause of the Functional Impairment (interference with activities of daily living) and the surgery is expected to restore or improve the Functional Impairment, AND

   2. The postoperative plan of care recommends compression garment use and continuation of conservative treatment, AND

   3. Surgical interventions must be performed by hospital credentialed, board certified plastic surgeon.

Liposuction for lipedema or lymphedema is not medically necessary when performed for cosmetic purposes (i.e., procedures or services that change or improve appearance without significantly improving Functional Impairment). Cosmetic surgery and any complications of cosmetic surgery are not eligible for coverage.

Liposuction for lipedema or lymphedema is considered investigational for use in the head, neck, trunk and back.

Re-treatment of a previously treated area using the same procedure is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

2. appropriate with regard to standards of good medical practice; and

3. not solely for the convenience of the Member, his or her Provider; and

4. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good 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. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

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.

POLICY HISTORY

03/15/2024: New policy added. Approved by the Medical Policy Advisory Committee.

10/08/2024: Medically necessary criteria updated to change "six consecutive months of conservative management" to "three to six consecutive months of conservative management."

08/01/2025: Policy reviewed; no changes.

SOURCE(S)

1. Blue Cross Blue Shield Alabama

2. Blue Cross Blue Shield North Carolina

3. 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.

4. Carl HM, Walia G, Bello R, et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg. Jul 2017; 33(6):412-425. PMID 28235214.

5. Hoffner M, Ohlin K, Svensson B, et al. Liposuction gives complete reduction of arm lymphedema following breast cancer treatment - A 5- year prospective study in 105 patients without recurrence. Plast Reconstr Surg Glob Open. Aug 16 2018; 6(8):e1912. PMID 30324078.

6. 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 .

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

Not Medically Necessary Codes

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