Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to 
Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The insurer denied: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The denial is overturned.

This adult female first began experiencing lymphedema swelling 18 years ago. She denied any trauma to the leg but can trace the start of the swelling back to her mid-twenties. In addition to the swelling, she reported nerve pain on the top of her leg, feeling of tightness, itching, aches, easy bruising, and throbbing cramps at night. Walking, running, strenuous exercise, standing or sitting for long periods of time, sitting in a car, flying on an airplane, salty or sugary or processed foods, dehydration, heat, or hot weather worsened her swelling. She attempted to control her symptoms by using her Flexitouch pump, self-manual lymphatic drainage ("MLD"), dry brushing, staying hydrated, and elevating her leg (mostly at night when sleeping improved swelling). She reported difficulties with bending at the knees and climbing the stairs. The patient saw a lymphedema therapist and her most recent session of comprehensive decongestive therapy ("CDT"). The patient used her Flexitouch compression pump five times a week for 45 minutes each time. She wore a custom Juzo Class 2 compression garment for approximately eight hours, four times a week, and a tribute garment nightly approximately three times per week. The patient reported that lymphedema has negatively affected her professional and home life. She used to be a pharmaceutical sales representative and her job consisted of getting in and out of the car multiple times a day when called on by physicians. Due to the swelling and pain in her 
leg, it became very difficult to keep up with her job, deal with the pain, and find comfortable clothes to wear to work due to her leg. As a direct result of this, she made the decision to stop working outside the home and has been a stay-at-home mom for the past 10 years. She has three children and finds it very hard to keep up with them because of her swelling, pain, and fatigue. 
The patient states that she has a hard time keeping up with regular household duties due to the intense pain and swelling.
None of the above measures were effectively reducing the size of her leg. 

The health plan should cover the proposed treatment.

Lymphaticovenous anastomosis (LVA) for this patient's leg edema is clinically appropriate and generally accepted as a potentially curative treatment for lymphedema. She has had debulking of her leg for her solid phase lymphedema. Now that the consolidated lymphedema has been removed, lymphaticovenous anastomosis is appropriate to prevent recurrent lymphedema. A 2020 Consensus Document of the International Society of Lymphology states (1): "Lymphatic-venous (or lymphovenous) anastomoses (LVA) are currently in use at many centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 25 years) and demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy)." In a study from MD Anderson Cancer Center, 95% of 
patients had subjective improvement in symptoms and 65% had objective improvement in swelling. The procedure has low morbidity with no complications recorded in the Chang series. 
A 2017 systematic literature review concluded (6): "Although the studies included in this review showed great heterogeneity, LVA surgery revealed both objective and subjective improvements in most patients." While prospective randomized studies have not been performed (and indeed would be exceedingly difficult to perform), these and other studies consistently show efficacy for 
lymphaticovenous anastomosis for breast cancer and lower extremity lymphedema such that the procedure should be considered a standard of care and not experimental. In addition, the requested two inpatient days are medically appropriate and would not be considered experimental/investigational when associated with the requested procedure.