Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted lipectomy (CPT 15879-50 bilateral anterior legs; CPT 15878-50 bilateral arms; CPT 15877 abdomen/trunk) and excision of excessive skin and subcutaneous tissue (CPT 15839 abdomen/trunk).Findings:  The physician reviewer found that adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. Although the condition is well described, it is relatively rare and often misdiagnosed One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult. Making the diagnosis relies on some of the hallmark characteristics of lipedema, such as the easy bruising and pain with soft tissue pressure, as well as the step-off at the ankles. Women with generalized obesity typically do not have these history and physical exam characteristics. Additionally, although many patients with lipedema may also be overweight, those who have tried to lose weight through diet and exercise typically find that reducing the size of their legs is very challenging, which is often not the case in women with standard obesity. This distinction is less clear, however, in women who have localized adiposity in the lower extremities that is not due to lipedema. Similar to lipedema, localized adiposity in some areas of the legs, particularly the outer thighs, around the knees, and the lower calves, can be very resistant to diet and exercise in some women. Further, some women with lipedema may also have additional areas of localized adiposity, making the diagnosis even more challenging. Reich-Schupke and colleagues report, The diagnosis [of lipedema] is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. In this case, the patient reported chronic fatigue, easy bruising, and difficulty standing, sitting, or squatting for extended periods of time. The records noted fat that was reported to be nodular in texture. The patient had a BMI of 29.24 and reported that she continued to steadily gain weight.  She did not respond to manual lymphatic drainage, did not have pitting edema, and Stemmers signs were negative. Photographs of the patient did not show ankle cuffing or disproportionate fat in the lower legs. A frontal photograph of the body showed fatty fullness in the upper arms, abdomen, lateral buttocks, hips, and thighs, sparing the lower legs and distal arm, without ankle or wrist cuffing. The fat distribution is not characteristic of lipedema, which characteristically terminates just proximal to the ankles. The records did not report weight loss affecting the legs. In this clinical setting, a diagnosis of clinically significant lipedema, in contrast to a diagnosis of exogenous obesity, cannot be made. Therefore, suction assisted lipectomy (CPT 15879-50 bilateral anterior legs; CPT 15878-50 bilateral arms; CPT 15877 abdomen/trunk) and excision of excessive skin and subcutaneous tissue (CPT 15839 abdomen/trunk) are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, exogenous obesity is not an abnormal structure of the body. Therefore, suction assisted lipectomy (CPT 15879-50 bilateral anterior legs; CPT 15878-50 bilateral arms; CPT 15877 abdomen/trunk) and excision of excessive skin and subcutaneous tissue (CPT 15839 abdomen/trunk) are not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.