Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Suction assisted lipectomy debulking to treat lymphedema
The insurer denied suction assisted lipectomy debulking to treat lymphedema.
The determination is overturned.

The patient has had a history of lymphedema. He has had multiple associated infections including cellulitis, groin and leg infections, septic infections, thrombus and related long term hospitalizations. His medical issues included his groin, scrotum and legs with resulting edema. He had confirming tests including magnetic resonance imaging (MRI) scans of the legs and nuclear scintigraphy which showed edema and fat hypertrophy of the legs along with abnormal back flow of lymph. He has tried and used conservative therapy with manual lymphatic drainage, compression, exercises, pneumatic devices, regular therapy appointments and 168 hours of management per week. His physician has written about his medical history along with the fact that patients who had chronic lymphedema also have abnormal fat growth that impairs the lymphatics. There are prior medical records consistent with his history as detailed above. There is a detailed medical history along with references from his surgeon regarding his surgery and prior history. There is a letter from the patient also detailing his extensive history and his use of every type of treatment for his lymphedema along with taking daily Penicillin for 7 years to prevent his related cellulitis. He had a confirming MRI of the lower extremities showing fat hypertrophy and a scintigraphy report confirming back flow of the lymphatic system.
His surgeon's note describes that the client has pitting edema and that he had "previously undergone a complete lymphatic work up and diagnosed with primary lymphedema with a fat dominant component... physical therapy (PT) maximization." The color photos of his legs show a dramatic size difference between his right and left legs in size. The proposed surgery is suction lipectomy of the abnormal fatty tissue of the lower extremities that is impacting his lymphedema. At issue is whether the suction assisted lipectomy debulking to treat lymphedema is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has primary lymphedema. He has a well documented record with life threatening illnesses related to his lymphedema. He has tried every type of treatment without success. He has supporting physical exams, MRI scan, lymph flow studies all of which are consistent with his diagnosis. All conservative treatments have not worked and as he said, he uses therapy 24 x 7 days per week. It is all but inevitable that his cellulitis will recur, which can be life threatening. The fat suction lipectomy is his last alternative and it has shown substantial success and is documented in the literature. It is likely to be more beneficial than other treatments (none of these have worked) and there are no alternatives (other then possibly lymph node surgery which is substantially more invasive). The patient is at significant medical risk of serious diseases and his quality of life is impacted due to his lymphedema. The procedure has been shown to work and is supported by the literature.

Per reference 1, suction-assisted lipectomy is an effective technique to reduce extremity volume for patients with lymphedema. Per reference 2, various types of treatment of lymphedema are under discussion and there has been some controversy regarding liposuction for lymphedema. Improvements in techniques, patient preparation, and patient follow-up have led to a greater and wider acceptance of liposuction as a treatment for lymphedema in patients with large chronic nonpitting extremity lymphedemas. Per reference 3, primary lymphedema is a chronic condition without a cure. The lower extremities are more commonly affected than the arms or genitalia. The disease can be syndromic. Morbidity includes decreased self-esteem, infections, and reduced function of the area. Recent Advances: Several mutations can cause lymphedema, and new variants continue to be elucidated. A critical determinant that predicts the natural history and morbidity of lymphedema is the patient's body mass index (BMI). Individuals who maintain an active lifestyle with a normal BMI generally have less severe disease compared to subjects who are obese. Because other causes of lower extremity enlargement can be confused with lymphedema, definitive diagnosis requires lymphoscintigraphy. Critical Issues: Most patients with primary lymphedema are satisfactorily managed with compression regimens, exercise, and maintenance of a normal body weight. Suction-assisted lipectomy is our preferred operative intervention for symptomatic patients who have failed conservative therapy. Suction-assisted lipectomy effectively removes excess subcutaneous fibro-adipose tissue and can improve underlying lymphatic function. Future Directions: Many patients with primary lymphedema do not have an identifiable mutation and thus novel variants will be identified. The mechanisms by which mutations cause lymphedema continue to be studied. In the future, drug therapy for the disease may be developed. Per reference 4, lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.