Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Lymphedema.
Treatment:  Vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.

The insurer denied coverage for vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.  The denial is overturned.

This is a female patient with a past medical history of cervical cancer.  The patient has undergone a laparoscopic hysterectomy, as well as pelvic lymph node dissection.  The patient was also treated with chemotherapy and radiation therapy in the past.  She subsequently developed bilateral pelvic lymphoceles and underwent drainage of the right infected lymphocele which resulted in suprapubic and bilateral lower extremity swelling. T he patient reported that she has been diagnosed with "stage III" lymphedema by physical therapy, and her condition has been exacerbated by her very active job causing her to take a medical leave.  The patient's current regimen was a 6 hour/day regimen of twice daily usage of a pneumatic pump as well as class II compression garment and self-performed manual lymphatic drainage.  The patient has had one episode of cellulitis to the suprapubic area and bilateral groin/upper thighs requiring hospitalization and intravenous (IV) antibiotics.  The clinical exam was consistent with stage II lymphedema characterized by gross increase in size of the affected suprapubic area and legs bilaterally.  The patient was a candidate for omental vascularized lymph node transfer.  A request was made for vascularized lymph node (omentum) flap transfer with microanastomosis and 1 associated inpatient bed stay.

As per literature review, there is scientific evidence to support improved clinical outcome in lymphedema with vascularized lymph node transfer.  The American Society of Plastic Surgery and Microsurgery Society have acknowledged that this is a known treatment.  As to date, lymphedema does not have a gold standard technique for surgery, and most non-operative interventions are supportive.  Lymph node transfer is a cutting edge new technique that has been supported in the literature and has been seen to have good results.  Gratzon et al. study found that "[vascularized lymph node transfer (VOLT)] continues to demonstrate its value as a safe and effective treatment option for lymphedema after breast cancer therapy.  Significant reductions in volume are accompanied by a decrease in symptoms and improvement in quality of life." Dionyssiou et al. study found that "[lymph node transfer (LNT) procedure] represents an effective therapeutic approach for stag II lymphedema patients; it significantly reduces limb volume, decreases recurrent infections and improve the overall function." 

Based on the review of the medical record, this patient's lymphedema has been refractory to non-operative treatment and has associated complications, including infection that required hospitalization.  This clinical presentation makes this patient a good candidate for the vascularized lymph node transfer. 

Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day should be overturned.