Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lymphedema
Treatment: Left Upper Arm Flexitouch Device 
The insurer denied a Left Upper Arm Flexitouch Device. The health plan's determination is upheld.

This female patient underwent chemotherapy, radiation, lumpectomy and axillary node dissection for left breast cancer and shortly thereafter developed left arm lymphedema with bouts of cellulitis. She had bariatric surgery. 1500cc liposuction of the arm was performed. Despite manual lymphatic drainage, compression and elevation, the limb swelling returned. A physical therapy note documents she had stopped exercises because she felt they did not work and overnight wrapping because it interfered with sleep with a left arm volume 32% greater than the right, a 5% increase from the previous month. Her surgeon requested a Flexitouch advanced compression device coverage and opined that a basic pump was ruled out over concerns of truncal swelling from limb lymph that could be squeezed from arm to trunk with conventional squeeze and hold compression.

Left Upper Arm Flexitouch Device is not medically necessary for this patient.
The gold standard treatment for lymphedema is complex decongestive therapy (CDT). This includes manual lymphatic drainage, compression bandaging, exercise, skin care, and education in self-management techniques. Although, pneumatic compression for extremity lymphedema results in meaningful improvement in the net health outcome there is insufficient evidence that treating the truncal/chest area in addition to the limb affected by lymphedema improves the outcomes of pneumatic compression pump therapy more than only treating the limb.
The only time a segmented, calibrated gradient pressure device would be indicated is when the individual has contractures or extensive scarring that prevents them from receiving satisfactory treatment from a non-segmented or segmented device without manual control due to safety concerns. Single or multi-chamber programmable pneumatic compression devices/lymphedema pumps (Flexitouch Plus is a programmable segmental pneumatic pressure device with programmable pumps) may be considered medically necessary for the treatment of lymphedema when:
1. The individual is otherwise eligible for non-programmable pumps
2. There is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression with single-compartment or multi-chamber non-programmable lymphedema pumps. This would only be considered for a small subset of patients with the following where non-programmable pumps cannot be utilized:
Extensive scarring or contracture of the treatment area, AND
When the scarring or contracture does not allow for standard segmented pneumatic compression therapy, meaning the chamber covering the scarring or contracture cannot be adjusted to allow for therapy [Not met because there is no documentation of scarring or contractures of the limb]
There is no data supporting the contention that non-segmental pumps on the extremities increase trunk edema. The use of calibrated pumps is considered not medically necessary in all other clinical situations. 
In this patient's case, medical necessity criteria for the Left Upper Arm Flexitouch Device are not met. There is no documentation of scarring or contractures of the limb that would not allow for standard compression therapy.