Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema. 
Treatment: Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 

The insurer denied the Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 
The health plan's determination is overturned. 

The patient is a female with chronic vulvar and bilateral lower extremities lymphedema following hemi-vulvovaginectomy with inguinal lymph node dissection and chemotherapy and radiation therapy for treatment of squamous cell carcinoma of a Bartholin's gland. Prior to her cancer diagnosis, she reports a gynecological-urology procedure, during which there was allegedly over-administration of Epinephrine, leading to a presentation of Takotsubo cardiomyopathy, confirmed by negative coronary angio and treated with an Intensive Care Unit (ICU) stay following 2 months of bedrest. Then she developed pain and swelling in the pelvic region which led to her subsequent cancer diagnosis. 
Her clinical examination is consistent with Stage II lymphedema, characterized by gross increase in size of the affected vulva and bilateral lower extremities due to edema and fibrofatty tissue deposits. She notes the labia gets "hard and leathery." She suffers from recurrent infections of the vulva that has required at least 4 hospitalizations with intravenous (IV) antibiotics. The patient has progressive lymphedema despite having maximized conservative medical therapy including compression garment, manual lymphatic massage, complete decongestive therapy with physical therapy and flexitouch pump. She feels compression worsens her leg swelling so she wears during exercise. Her symptoms have a severe impact on her quality of life and impacts her activities of daily living. Lymphatic mapping of the lower extremities show dermal backflow which demonstrate indication for lymphaticovenous anastomosis. Her surgeon believes vascularized lymph node transfer to the groin is indicated for vulvar lymphedema with recurrent infections. 

Vascularized lymph node transfer is medically necessary and the most appropriate treatment for this patient. Compression therapy is the mainstay of treatment, but the medical literature indicates that microsurgical lymph node transfer or lymphaticovenous anastomosis provides better control of edema when compared to compression. Moreover, this patient has failed to respond to compression therapy. Studies by Gharb et al., Lin et al. and Becker et al. confirm that microvascular lymph node transfer is an effective treatment for post-mastectomy lymphedema. In the Becker study, all but two patients were either cured or significantly improved with microvascular lymph node transfer, and the study by Lin et al. reported significant improvement in limb circumference and reduction in episodes of cellulitis with lymph node transfer to the wrist. This study had an average follow-up of 56.3 months with no recurrence. 

According to a review of 24 published studies: "Vascularized lymph node transfer (VLNT) for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment." A meta-analysis of vascularized lymph node transplant for mastectomy lymphedema concluded: "Current evidence indicates that VLNT can improve volume difference between arms in unilateral lymphedema patients by about 40%. In addition, although based on few studies, it is likely that VLNT has a positive effect on patients' quality of life, the number of skin infections and compression garment usage while coinciding with a low complication rate." Another 2021 meta-analysis concluded: "Intra-abdominal VLNT is an effective technique for patients with lymphedema with no obvious impairment to donor-site lymph function, as long as the operation is properly performed."